Infectious Diseases
COVID-19: Treatment
Initial/Prep/Goals
- CDC currently recommends quarantine/universal precautions
- See prevention guidelines
- Separate triage of patient with respiratory conditions
- Immediate application of surgical mask on all patients with respiratory conditions
- If COVID-19 suspected after triage
- Immediate isolation
- Transfer to negative pressure rooms
- Healthcare personnel use full protective gear and precautions (i.e., contact precautions, airborne precautions, eye protection)
- Recommend isolation at least 24 hours after both symptom resolution overall and no fever (including not using fever-reducing medication)
- Depending on the length of symptoms, isolation could be shorter, the same, or longer than 5 days of the previous guidance for COVID-19
- If COVID-19 is diagnosed
- Notify infection control within the institution
- Maintain a list of all hospital personnel who may have been in contact
- Notify the County Health Department per local protocol
- Routine resuscitation as needed
- IV fluids
- Supplemental oxygen
- Non-invasive ventilatory support as necessary
- Intubation Considerations
- COVID-19 may cause hypoxemia even in the setting of little respiratory distress
- May be profoundly hypoxemic without dyspnea (patients may "look" fine)
- Work of breathing cannot be relied upon to detect patients who are failing on high-flow nasal cannula (HFNC)
- Consider a lower threshold for intubation indications
- Patients can develop worsening "silent" atelectasis and decline quickly and abruptly without lots of symptoms
- Oxygenation techniques to maintain saturation during intubation may increase virus aerosolization (e.g., mask ventilation)
- "Pure" rapid sequence intubation without bagging is preferred
- Consider viral filter to BMV
- This will be safer if the patient is starting out with more oxygenation reserve
- Consider semi-elective intubation over crash intubation (decreases prep time)
- Intubation procedure can place healthcare workers at risk of acquiring the virus
- Endotracheal tube confirmation could pose an inoculation risk to a practitioner
- Pulmonary complications by COVID-19
- Atelectasis (consider PEEP, APRV, ARDSnet)
- Alveolar fluid filling (drain fluid- prone positioning with ventilation, APRV, coughing or "dumping" breaths to help clear lungs)
- WHEN TO INTUBATE?
- Physician clinical decision
- Consider if
- Progressively rising FiO2 requirements (e.g. > 75% FiO2 - again, based on patient's status)
- High flow cannula does not improve oxygenation
- Comorbid conditions (e.g., COPD, asthma, cardiovascular disease, DM, etc.
- Supportive therapy (Inpatient)
- IV fluids PRN, Antipyretics PRN, Oxygen PRN, Monitors
- Target SpO2 of 92% to 96%
- Optimal oxygen saturation is uncertain for those receiving supplemental oxygen
Medical/Pharmaceutical
- Supportive therapy (inpatient moderate to critical illness):
- Hospitalization for routine monitoring of vitals
- If undergoing procedures that generate aerosols (sputum production, intubation, HFNO, BiPAP/CPAP, etc.)
- Isolate: single private negative pressure isolation room with HEPA filter
- If no isolation room available: be extremely cautious when applying airway devices that deliver ≥ 6 L/min O2 (if not intubated) - may generate aerosols
- High-flow nasal oxygen can give a fraction of inspired oxygen (FiO2) up to 100% and reduces the need for intubation
- Apply airborne precautions
- BiPAP and CPAP should be avoided if possible
- Use with caution if necessary
- If a private room not possible: keep ≥ 2 ft distance between patients
- If concomitant asthma or COPD
- Bronchodilators: use metered dose inhalers with a spacer instead of nebulizers (risk of aerosolization)
- Continue treatment with inhaled corticosteroids; consider escalation of asthma treatment as needed
- If severe asthma/COPD: consider epinephrine and early RSI
- Consult Infectious Disease and Pulmonology services early
- Conservative fluid management
- Net fluid balance of 0 mL over first 7 days if ARDS and not hypotensive or shock
- If suspect sepsis:
- Empiric antibiotics (CAP vs HCAP) within 1 hr of recognition of sepsis, then work-up source of infection
- Do not use hydroxyethyl starches for intravascular volume replacement
- If flu season or suspect flu
- If respiratory failure (hypercarbic or hypoxic)
- Strongly consider advanced ventilatory support/intubation
- DO NOT share ventilators
- Hypoxemic respiratory failure
- If conventional oxygen therapy failed: use a high-flow nasal cannula
- If the high-flow nasal cannula not available and no indication for endotracheal intubation: perform a noninvasive ventilation trail and monitor closely
- If the high-flow nasal cannula is required and no indication for endotracheal intubation: perform a trail of awake prone positioning
- Do NOT use awake prone positioning as rescue therapy to avoid intubation
- Acute respiratory distress syndrome (ARDS)
- Use low total volume (VT) ventilation (VT 4–8 mL/kg of predicted body weight) over higher VT ventilation (VT >8 mL/kg)
- Target plateau pressures of <30 cm H2O
- Use a conservative fluid strategy over a liberal fluid strategy
- Do not use inhaled nitric oxide routinely
- Moderate to severe ARDS with mechanical ventilation
- Use a higher positive end-expiratory pressure (PEEP) strategy over a lower PEEP strategy
- If refractory hypoxemia despite optimized ventilation, use prone ventilation for 12 to 16 hours per day
- No current recommendations for extracorporeal membrane oxygenation in refractory hypoxemia
- As needed administer intermittent boluses of neuromuscular blocking agents or a continuous neuromuscular blocking agent infusion
- Severe ARDS, COVID-19, and hypoxemia despite optimized ventilation
- Use an inhaled pulmonary vasodilator as a rescue therapy
- if no rapid improvement in oxygenation, taperer treatment
- Use recruitment maneuvers
- Do not use staircase (incremental PEEP) recruitment maneuvers
-
- If refractory hypoxemia even with advanced ventilatory support
- Consider extracorporeal membrane oxygenation (ECMO) if available
- Do NOT use awake prone positioning as rescue therapy to avoid intubation
- Gohibic (vilobelimab) injection
- FDA EUA use for tx of COVID-19 in hospitalized adults within 48 hours of
- Receiving invasive mechanical ventilation or ECMO
- Recommended dosage: 800 mg administered by IV infusion after dilution
- Given up to 6x over the treatment period
- Shock: volume support and pressors:
- Pressors
- Albumin NOT recommended for initial use
- Do NOT use hydroxyethyl starches for intravascular volume replacement
- If cardiac dysfunction and persistent hypoperfusion despite adequate fluids and pressors:
- If septic shock and a history of corticosteroid course completion for COVID-19
- Use low-dose corticosteroid therapy over no corticosteroid therapy
- Corticosteroids
- Potentially beneficial
- Dexamethasone
- RECOVERY trial: dexamethasone (6 mg PO/IV daily for up to 10 days)
- Reduced 28-day mortality in certain groups of hospitalized COVID-19 patients
- Indications
- Mechanically ventilated
- Require supplemental oxygen
- Contraindications
- COVID-19 patients who do not require supplemental O2
- ACEi/ARB therapy: short-term/long-term effects in COVID-19 risk/outcomes still unclear
- Current recommendations: continue ACEi/ARB therapy during treatment of COVID-19 unless there is a contraindication
- Not recommended to start ACEi/ARB therapy explicitly for the treatment of clinical sequelae from COVID-19
- Remdesivir
- Has not shown to be effective in reducing mortality as monotherapy
- Consider combination with baricitinib in severe COVID-19
- Who cannot receive a corticosteroid
- IV nucleotide prodrug (adenosine analog)
- Binding to viral RNA-dependent RNA polymerase
- Inhibits viral replication by premature termination of RNA transcription
- Start within 7 days of S/S onset
- Day 1 loading dose: 200 mg IV infused over 30 to 120 mins, then
- Day 2 and onwards: 100 mg IV qDay
- Treatment duration 5 days, if no improvement clinically can extend treatment up to 10 days total.
- If invasive mechanical ventilated or extracorporeal membrane oxygenation: 10 days
- eGFR ≥ 30 mL/min: no dose adjustment
- eGFR < 30 mL/min: not recommended
- Combination therapy with corticosteroids may be beneficial for severe COVID-19; remdesivir alone showed a decrease in time to recovery compared to remdesivir and corticosteroids
- FDA approval for use in hospitalized adult and pediatric patients (aged ≥ 12 years of age and ≥ 40 kg)
- Pediatric patients: 3.5-40 kg, or aged < 12 years and weighing ≥ 3.5 kg
- Nirmatrelvir/ritonavir
- FDA approved for COVID-19
- Preferred agent by NIH
- Dosing based on renal fxn
- eGFR > 60 mL/min
- 300 mg/100 mg (nirmatrelvir/ritonavir, co-admin) PO q12hr x5 days
- eGFR ≤ 60 mL/min and ≥ 30 mL/min
- 150 mg/100 mg (nirmatrelvir/ritonavir, co-admin) PO q12hr x5 days
- eGFR < 30 mL/min
- If hospitalization occurs during Tx course
- May complete Tx per providers discretion
- Administration:
- Take with/without food
- Co-admin nirmatrelvir and ritonavir tabs
- Swallow whole; do not crush, chew, split tabs
- Missed dose: if ≤ 8 hrs take a dose, otherwise skip
- IDSA recommendation
- Recommended for use in ambulatory pts w/ mild-to-moderate COVID-19 at high risk for
- Progression to severe disease
- Nirmatrelvir/ritonavir should be initiated w/in 5 days of symptom onset
- Rather than no tx w/ nirmatrelvir/ritonavir
- Molnupiravir
- FDA EUA for COVID-19
- 800 mg PO q12h x5 days
- Initiate within 5 days of S/S onset
- Safety/efficacy of >5 days Tx not established
- If hospitalization occurs during Tx course
- May complete Tx per providers discretion
- Administration:
- Take with/without food
- Swallow whole; do not open, crush, chew
- Missed dose: take asap if ≤10 hrs since missed, otherwise skip
- Baricitinib
- FDA-approved for COVID-19 in hospitalized adults requiring supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO
- Dosing based on renal function
- eGFR ≥60 mL/min: 4 mg PO QD
- eGFR 30 to <60 mL/min: 2 mg PO QD
- eGFR 15 to <30 mL/min: 1 mg PO QD
- eGFR <15 mL/min/: Not recommended
- Dosing may be adjusted due to adverse reactions, follow baricitinib monograph for further details
- Administration
- Take with/without food
- PO, oral dispersion in water, via gastronomy/nasogastric/orogoastric tube
- Duration
- 14 days or until discharge
- Bebtelovimab (not currently authorized in any US region; not effective against BQ.1 and BQ.1.1 variants)
- FDA EUA for COVID-19
- 175 mg IV x1
- Admin ASAP after positive results and ≤ 7 days of S/S onset
- Administration
- Admin as single IV injection for ≥30 sec in a healthcare setting
- Monitor for IRRs for ≥ 1 hr after infusion
- Authorized for mild-to-moderate COVID-19 in
- Adults
- Children (12 years and weighing at least 40 kg)
- Do not use in patients, who:
- Hospitalized due to COVID-19, OR
- Require oxygen therapy and/or respiratory support due to COVID-19, OR
- Require an increase in baseline oxygen flow rate and/or respiratory support due to COVID-19 and are on chronic oxygen therapy and/or respiratory support due to underlying non-COVID-19 related comorbidity
- Used to prevent progression to severe COVID-19 and
- Do not have access or clinically inappropriate for other treatments
- Interferon alfa/beta
- NIH recommends against the use for:
- Nonhospitalized pts with mild to moderate COVID-19, except in clinical trials
- Hospitalized pts, except in clinical trials
- Interleukin-6 inhibitors
- IDSA recommends tocilizumab in patients with elevated CRP in addition to steroids
- Sarilumab in addition to steroids if tocilizumab is not available
- Anti-SARS-CoV-2 monoclonal antibodies
- No longer authorized due to ineffective neutralization of current COVID-19 dominant circulating variants
- NIH recommends against the use of anti-SARS-CoV-2 mAbs for treatment or prevention of COVID-19
- Investigational Therapy
- Interferon gamma 1b
- RCT from Hong Kong
- Concomitant with lopinavir/ritonavir and ribavirin (triple therapy) yielded quicker clinical improvement and reduced viral shedding
- Suspect most of the benefits derived from interferon
- However, many hesitate its use since it tends to make people feel terrible
- Phase II inhaled formulation trial yielded favorable results
- IVIG
- NIH recommends against the use for Tx of COVID-19, except in clinical trials
- Anecdotally reported:
- Sarilumab (anti-IL6R)
- Anakinra (anti-IL1)
- IDSA guideline panel suggests against routine use in hospitalized patients w/ severe COVID-19
- Most effective when used ≥ 10 days, doses ≥ 100 mg, IV administration, and initiated early
- Potential to prevent progression to severe disease
- anti-GM-CSF
- GM-CSF
- Siltuximab (anti-IL6): 11 mg/kg IV single dose
- IL-6 antagonist monoclonal antibody
- Under trial for serious COVID-19 cases
- Camostat mesilate
- Serine protease inhibitor used in Japan for treatment of pancreatitis; shown to inhibit SARS-CoV 2 entry into human lung cells (in vitro)
- Not found to be effective or affect clinical improvement, progression, or mortality
- Favipiravir (Asia only) + IFN-α1b inhalation
- Meta-analysis of RCTs found favipiravir to have no benefit in reducing ICU admission, oxygen therapy requirements, and viral clearance
- Open-label, nonrandomized control study showed improved viral clearance time and chest CT vs lopinavir/ritonavir in non-severe, non-ICU pts
- Investigational dosing:
- Hospitalized with < 7 days since signs/symptoms onset: 1600 mg PO BID for 1 day, then 600 mg PO BID (7-14 days total Tx)
- Convalescent plasma transfusion
- Definition
- Has been used as passive immunotherapy for infections for > 100 years
- In recent years, studies derived from people who had recovered from specific infections showed encouraging results
- However, these studies were typically small, non-randomized and largely descriptive
- Transfusion of COVID-19 virus antibody-rich plasma
- IDSA recommendation
- Against the use of COVID-19 convalescent plasma
- For ambulatory patients w/ mild-to-moderate COVID-19 at high risk for progression
- To severe disease and who have no other treatment options
- Suggests the use of FDA-qualified high-titer COVID-19 convalescent plasma
- Within 8 days of symptom onset, rather than not given
- For immunocompromised patients hospitalized w/ COVID-19
Surgical/Procedural
- Possible intubation/mechanical ventilation as needed
Special Considerations
- Critical Care Guidelines (interim)
- See flowchart illustration (View image)
- See guidelines from the Society of Critical Care Medicine (SCCM)
- Immunity and Reinfection Risk
- Individuals who have been infected are normally induced with antibodies
- Preliminary studies suggest some of the antibodies are protective
- Evidence is not confirmed
- Unknown whether immunity in previously infected patients is sufficient for protective purposes and how long immunity will last
- NOTE: FDA has granted EUA for tests that qualitatively identify antibodies against SARS-CoV-2 in serum or plasma
- Pregnant women
- Do not withhold COVID-19 vaccination due to pregnancy/lactation
- Intrauterine or perinatal transmission has not been identified
- Clinical guidelines for pregnant women with suspected COVID-19 should be similar to those in nonpregnant individuals except for:
- NIH recommends against using molnupiravir unless no other options are available
- ACOG indicates that infants born to mothers with confirmed COVID-19 should be considered a patient under investigation and appropriately isolated and evaluated
- Individual agents during pregnancy NIH recommendations
- Recommended in hospitalized Pts if indicated:
- Recommended if indicated: remdesivir, nirmatrelvir/ritonavir
- Recommended against: molnupiravir
- Breastfeeding
- Unknown whether the virus can be transmitted through breast milk
- Droplet transmission could occur through close contact during breastfeeding
- Therefore, while breastfeeding, mothers should use appropriate hand hygiene and a facemask
- Consider having a different individual feed expressed breast milk to the infant
- Individual agents during lactation:
- Breastfeeding may continue, the agent should be offered:
- abatacept, dexamethasone, heparin (LMWH/UFH), infliximab, remdesivir, nirmatrelvir/ritonavir, tocilizumab
- Breastfeeding not recommended during and for 4 days after the last dose:
- Avoid breastfeeding during and for 4 days after last dose:
- Pediatric COVID-19
- NIH Guidelines
- Risk level based on health conditions for COVID-19 progression
- High risk
- Moderately or severely immunocompromised regardless of the vaccine status
- Vaccination status not up to date AND:
- Obesity
- Respiratory technology dependence
- Severe neurologic, genetic, metabolic, or other disability that results in impaired airway clearance or limitations in self-care or activities of daily living
- Severe asthma or other severe chronic lung disease requiring ≥2 inhaled or ≥1 systemic medications daily
- Severe congenital or acquired cardiac disease
- Multiple moderate to severe chronic diseases
- Pregnancy
- Intermediate risk
- < 1 y/o
- Premature and ≤2 y/o
- Sickle cell disease
- Diabetes mellitus (poorly controlled)
- Chronic kidney disease
- Nonsevere cardiac, neurologic, or metabolic disease
- Vaccination status up to date AND:
- Obesity
- Respiratory technology dependence
- Severe neurologic, genetic, metabolic, or other disability that results in impaired airway clearance or limitations in self-care or activities of daily living
- Severe asthma or other severe chronic lung disease requiring ≥2 inhaled or ≥1 systemic medications daily
- Severe congenital or acquired cardiac disease
- Multiple moderate to severe chronic diseases
- Pregnancy
- Low risk
- Mild asthma
- Overweight
- Diabetes mellitus (well controlled)
- Treatment plan
- Nonhospitalized
- Symptomatic - supportive care
- High risk
- 12-17 yo: start either nirmatrelvir/ritonavir or remdesivir
- < 12 yo: nirmatrelvir/ritonavir not approved. Consider remdesivir based on age and risk factors
- Intermediate risk - insufficient evidence
- Low risk - supportive care
- Hospitalized
- Start supportive care
- ≥12 yo, use prophylactic anticoagulation unless contraindicated
- No supplemental oxygen required
- If high risk of progression, consider remdesivir for 12-17 y/o
- Conventional oxygen required
- Start remdesivir
- Add dexamethasone if oxygen needs increase
- HFNC or NIV required
- Start dexamethasone or dexamethasone and remdesivir
- If no improvement in oxygenation within 24 hrs, consider adding baricitinib or tocilizumab for children ≥2
- ECHMO or MV required
- Start dexamethasone
- If no improvement in oxygenation within 24 hrs, consider adding baricitinib or tocilizumab for children ≥2
- COVID-19 and Kawasaki Disease in the Pediatric Population
- There are reports of children experiencing Kawasaki disease secondary to COVID-19 infection
- Particularly in Europe and more recently in the United States
- Most children with COVID-19 are asymptomatic or exhibit only mild symptoms
- Recently, a small number of children developed a serious inflammatory syndrome due to underlying COVID-19 infection
- Inflammatory symptoms were found to be Kawasaki Disease-like
- Fever 102-104°F for ≥ 5 days
- Lymphadenopathy
- Erythematous morbilliform rash
- Conjunctival injection
- Erythema/swelling of hands and feet with desquamation
- Oral mucositis
- Progression in disease may cause
- Persistent fever
- Inflammation
- Toxic shock syndrome
- Single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal, or neurological disorder)
- Children may have some/all the features of Kawasaki disease
- Hospitalization and intensive care were required in some cases
- Prompt diagnosis and treatment is essential
- Usually self-limited and most children resolve with treatment in 5-6 weeks
- 25% of patients have cardiac sequelae (e.g., MI, coronary artery aneurysm)
- Please see the monograph for further diagnostic/management details of Kawasaki Disease
- MIS-C ASSOCIATED WITH COVID-19 in the Pediatric Population Use of Specific Medications
- Multi-system inflammatory syndrome in children associated with COVID-19 Criteria:
- An individual aged < 21 years of age presenting with:
- Fever (Fever > 38.0°C for ≥ 24 hrs, or report of subjective fever lasting ≥ 24 hrs)
- Lab evidence of inflammation (Including, but not limited to, ≥ 1:
- Elevated: CRP, ESR, fibrinogen, procalcitonin, D-dimer, ferritin, LDH, IL-6, neutrophils
- Reduced: lymphocytes, albumin
- Evidence of clinically severe illness
- Hospitalization
- Multisystem (> 2) organ involvement
- No alternative plausible diagnoses
- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test
- Exposure to COVID-19 case within 4 weeks prior to onset of symptoms
- Some individuals may fulfill full or partial criteria for Kawasaki disease but should be reported if they meet the case definition for MIS-C
- Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection
- Clinical presentation includes:
- Fever
- Red eyes/Red cracked lips
- Abdominal pain
- vomiting
- Diarrhea
- Skin rash
- musculocutaneous lesion
- Swollen Hands and Feet
- Hypotension, shock (severe cases)
- Other evaluations include:
- Echo
- EKG
- Cardiac enzymes and troponin testing
- Lactate
- BNP, NT-proBNP
- Treatment
- Fluid Resuscitation
- Balancted crystalloids are recommended over 0.9% normal saline or albumin if shock is present for initial resuscitation
- Inotropic support
- Epinephrine or norepinephrine recommended over dopamine
- Respiratory support
- Anti-inflammatory measures (Steroids/IVIG)
- NIH treatment recommendations
- Initial
- IVIG 2g/kg IBW IV (up to max total dose of 100 g) PLUS low-moderate dose methylprednisolone (1-2 mg/kg/IV) or another glucocorticoid at equivalent dose
- Glucocorticoid monotherapy, only if IVIG is unavailable/contraindicated
- IVIG monotherapy, only if glucocorticoids are contraindicated
- Intensification
- Recommended when no improvement within 24 hrs of initial immunomodulatory Tx
- High dose anakinra 5-10 mg/kg/day IV (preferred) or SUBQ in 1–4 divided doses
- Higher-dose glucocorticoid (methylprednisolone 10–30 mg/kg/day IV for 1–3 days, up to a maximum of 1,000 mg/day, or equivalent glucocorticoid for 1–3 days)
- Infliximab 5–10 mg/kg IV x 1 dose
- Please see the monograph for further diagnostic/management details of MIS-C
- Corticosteroids
- Patients on chronic corticosteroids for another underlying condition should not discontinue its use
- Poorly controlled asthma/COPD may lead to a more complicated disease course
- However, asthma/COPD does not seem to be a risk factor for acquiring COVID-19
- Systemic corticosteroids are the mainstay of management of systemic inflammation
- For patients w/ severe COVID-19 infection
- Ciclesonide
- Demonstrates the ability to block SARS-CoV-2 viral replication in vitro
- May offer both anti-inflammatory and antiviral activity
- Did not reduce time to recovery
- In patients w/ severe disease on corticosteroids
- IDSA suggests baricitinib to be added, rather than no baricitinib
- Baricitinib 4 mg/day (or appropriate renal dosing) up to 14 days or until discharge
- Shows most benefit in pts w/
- Severe COVID-19 on high-flow O2/non-invasive ventilation
- ACE inhibitors/ARBs
- Despite ACE2 being a receptor for SARS-CoV-2, patients taking ACE inhibitors and ARBs should continue treatment with these agents
- There is no evidence to support a more severe course of infection by taking these agents
- Consider the individual patient needs before making any changes
- Stopping these medications may exacerbate comorbid cardiovascular/kidney disease thereby increasing mortality
- Angiotensin II reported to be significantly elevated in COVID-19 patients
- Linear positive correlation to viral load and lung injury
- However, no data suggests immediate need to initiate RAAS inhibitors unless comorbid indication exists
- Statins
- Continue statins in hospitalized patients with COVID-19 who are already taking them
- Many severe COVID-19 patients have underlying
- Cardiovascular disease
- Diabetes mellitus
- Other indications for use of statins
- Also, statins are indicated because acute cardiac injury is a reported complication of COVID-19
- Whether statins could impact the course of SARS-CoV-2 infection is not clear
- Immunomodulators
- Immunocompromised patients with COVID-19
- At increased risk for severe disease
- Decision to terminate immunomodulators
- Must be determined on a case-by-case basis
- For individuals who require treatment with these agents and DO NOT have COVID-19 infection
- There is NO evidence supporting the routine discontinuation of the drugs
- AGA Recommendations for Immunomodulator use in IBD for COVID-19
- IBD patients with symptomatic COVID-19 (e.g., fever, respiratory symptoms, GI symptoms, etc.) should stop medications after consultation with GI or primary care physicians
- Drugs to be temporarily discontinued include thiopurines, methotrexate, tofacitinib, and anti-TNFs (i.e., ustekinumab and vedolizumab)
- However, some drugs may still be continued for IBD (i.e., aminosalicylates, topical rectal therapy, dietary management, oral budesonide, and antibiotics)
- NSAIDs
- FDA and WHO indicate current epidemiologic evidence is not sufficient to advise against NSAIDs in COVID-19 pts
- WHO retracted earlier warning against the use of ibuprofen
- Warning was due to theoretical mechanism suggesting NSAIDs increase expression of ACE2, the receptor by which the coronavirus enters host cells
- It was unclear whether harm was associated with intermediate or prolonged use of NSAIDs
- Currently, discontinuation of chronic ibuprofen use is not advised
- WHO and NHS suggest acetaminophen is preferred to treat pain and fever until more evidence is collected
- Stronger evidence is needed to deduce causation of harmful effect of ibuprofen in COVID-19 patients
- Avoid nebulized medications
- Avoid the risk of aerosolization of SARS-CoV-2 through nebulization
- Use metered dose inhaler for inhaled medications
- Use appropriate infection control measures
- Fluvoxamine
- NIH recommends against use for nonhospitalized COVID-19 pts
- If used for an underlying condition, continue Tx
- Ivermectin
- Do NOT use for Tx of COVID-19
- Metformin
- NIH recommends against use for hospitalized COVID-19 pts, except in clinical trials
- If used for an underlying condition, continue Tx
- Colchicine
- Failed to show benefit in trails
- Vitamin C
- NIH recommends against use for hospitalized COVID-19 pts
- Vitamin D
- Zinc
- Do not use the above recommended dietary allowance, except in clinical trials
- 11 mg QD for men; 8 mg QD for nonpregnant women
Complications
- Long COVID
- Death
Prevention
- Avoid endemic areas and persons who've traveled to endemic areas
- CDC recommends everyone ages ≥ 6 months
- Receive an updated 2024-2025 COVID-19 vaccine
- To protect against the potentially serious outcomes of COVID-19 this fall and winter
- Whether or not they previously have been vaccinated with a COVID-19 vaccine
- COVID-19 Vaccines
- Pre-Exposure Prophylaxis
- Cilgavimab/Tixagevimab
- No longer authorized for use in the US until further notice by FDA
- < 10% of circulating variants in the US are susceptible to Evusheld
- Pemgrada (pemivibart)
- FDA EUA (issued March 22, 2024) for COVD-19 in
- Adults and adolescents ≥ 12 yo and weighing ≥ 40 kg (≥ ~88 lbs)
- Authorized for individuals
- Who are not currently infected w/ SARS-CoV-2 and
- Have not had a known recent exposure to an individual infected w/ SARS-CoV-2
- AND who have moderate-to-severe immune compromise due to a medical condition or
- Due to taking immunosuppressive medications or treatments and
- Are unlikely to mount an adequate immune response to COVID-19 vaccination
- Post-Exposure Prophylaxis
- VTE Prophylaxis
- Adults who require low-flow oxygen and do not require ICU-level care
- Recommendation: use a therapeutic dose of heparin for pts w/ D-dimer levels above ULN
- If pt requires low-flow oxygen and does not have increased bleeding risk
- Adults who require ICU-level care, including those receiving high-flow oxygen
- Recommendation: use of prophylactic dose of heparin as VTE prophylaxis (unless CI exists)
- Intermediate dose (e.g., enoxaparin 1 mg/kg once daily) or
- Therapeutic dose of anticoagulation for VTE prophylaxis
- Pts on a therapeutic dose of heparin in a non-ICU setting due to COVID-19 and then transferred to ICU, the panel recommends switching to a prophylactic dose of heparin unless VTE confirmed
- Duration of anticoagulation
- Continue Tx until either of the following occurs first:
- 14 days of anticoagulation: switch to prophylactic anticoagulation until discharge
- Transfer to ICU: continue anticoagulation until discharge
- Pt discharged
- Contraindications to anticoagulation due to increased risk of bleeding with COVID-19
- Platelet count <50,000 cells/µL
- Hemoglobin <8 g/dL
- Need for dual antiplatelet therapy
- Bleeding within the past 30 days that required an emergency department visit or hospitalization
- History of a bleeding disorder
- Inherited/active acquired bleeding disorder
- Special considerations during pregnancy and lactation
- Pregnant pts who are receiving anticoagulation/antiplatelet tx should continue even after COVID-19 dx
- Recommends use of a prophylactic dose of anticoagulation for pregnant pts hospitalized due to COVID-19
- Unless CIs exist
- Continuation of VTE prophylaxis in pregnant/postpartum pt after discharge should be
- Individualized, with consideration of concomitant VTE risk factors
- Anticoagulation therapy during labor and delivery requires specialized care and planning
- UFH, LMWH, and warfarin do not accumulate in breast milk and
- Do not induce anticoagulant effect in newborn
- Can be used by breastfeeding individuals who require VTE prophylaxis or tx
- CDC Strategies for Personal Protective Equipment (PPE) Shortages
- Limited availability of personal protective equipment (PPE) has complicated the care of patients and the protection of healthcare providers (HCP) worldwide
- CDC guidance on optimizing the supply of PPE:
- Canceling non-urgent procedures or visits that would warrant the use of PPE
- Prioritize the use of certain PPE for the highest-risk situations
- Consider allowing HCPs to extend the use of respirators, facemasks, and eye protection, beyond a single patient contact
- If no commercial PPE is available, carefully consider if alternative approaches will reduce the risk of HCP exposure and are safe for patient care (i.e., home-made PPE)
- Cautious/limited reuse of PPE
- NOTE: as PPE becomes available, healthcare facilities should promptly resume standard practices
- Decontamination of PPE for reuse (particularly for N95 respirators)
- Under normal circumstances, CDC and NIOSH do not recommend that PPEs be decontaminated and then reused as standard care
- Disposable filtering facepiece respirators (FFR) decontamination and reuse may need to be considered as a crisis capacity strategy to ensure continued availability
- Methods for decontamination
- Ultraviolet light
- Hydrogen peroxide vapor
- Moist heat
- OSHA Interim Guidance
- Appropriate respiratory protection required if providing direct care of these patients
- Conserve supplies of these respirators while safeguarding HCP
- Healthcare employers may provide HCP with another respirator of equal or higher protection
- N99 or N100 filtering facepieces
- Reusable elastomeric respirators with appropriate filters or cartridges
- Powered air purifying respirators
- Change method of fit testing from destructive (i.e., quantitative) to non-destructive method (i.e., qualitative)
- For filtering facepiece respirators, qualitative and quantitative fit-testing methods are both effective at determining whether the respirator fits properly
- Use only NIOSH-certified respirators
- Implement CDC/OSHA strategies for optimizing supply of N95 filtering facepiece respirators and prioritizing their use
- Perform initial fit tests for each HCP with the same model, style, and size respirator that the worker will be required to wear for protection against COVID-19
- Initial fit testing is essential
- N95 filtering facepiece respirators should be preserved and prioritized for use in situations where they are required to be worn
- Perform user seal check (i.e., a fit check) at each donning
- Conduct fit test if observe visual changes in wearer if it could affect respirator fit (e.g., facial scarring, dental changes, cosmetic surgery, or obvious changes in body weight)
- Inform supervisor/administrator if integrity and/or fit of N95 filtering facepiece respirator is compromised
- NOTE: inspect N95 respirator to determine if the structural and functional integrity of the respirator has been compromised
- Straps, nose bridge, nose foam materials may degrade
- If integrity is compromised, or if a successful user seal check cannot be performed, discard
- CDC Mask Guidance
- Fully vaccinated people can resume activities that they did prior to the pandemic
- Fully vaccinated people can resume activities without wearing a mask or physically distancing
- Exception: where required by federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance
- Home-made Cloth Face Mask
Disposition
- Admission Criteria
- Decision to monitor inpatient vs outpatient settings should be made on a case-by-case basis; consider
- Clinical presentation, patient's ability to self-monitor, home isolation, and risk of transmission in home environment
- Patients with mild clinical presentation may not initially require hospitalization
- Clinical signs/symptoms may worsen (e.g., lower respiratory illness progression due to comorbidities)
- All patients should be monitored closely
- Consider
- Home Care
- CDC guidelines for discontinuation of home isolation
- If you test positive
- Quarantine can end after Day 5 if asymptomatic
- Continue to wear a mask around others for 5 additional days
- If you have a fever
- Continue to stay home until your fever resolves
- If you have been boosted, had completed Pfizer/Moderna vaccine < 6 months or complete J&J < 2 months
- Wear a mask around others for 10 days
- Test on day 5, if possible
- Development of symptoms, get a test and stay home
- If you completed the Pfizer/Moderna vaccine > 6 months ago and are not boosted, completed J&J > 2 months ago and are not boosted or unvaccinated
- Stay home for 5 days, wear a mask for 5 additional days around others afterwards
- If you cannot quarantine, wear a mask for 10 days
- Test on day 5 if possible
- If symptomatic, get a test and stay home
- Consult(s)
- Local health dept and CDC
- Discharge/Follow-up Instructions
- Stopping Transmission-based Precautions for COVID-19
- Meeting criteria is NOT indication for discharge
- Symptomatic COVID-19 patients should remain in transmission-based precautions until either
- Symptom strategy
- ≥ 3 days (72 hrs) since recovery, defined as:
- Resolution of fever without use of antipyretics AND
- Improvement of respiratory symptoms AND
- ≥ 10 days since onset of symptoms
- Test-based strategy
- Resolution of fever without use of antipyretics AND
- Improvement of respiratory symptoms AND
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from ≥ 2 consecutive respiratory specimens collected ≥ 24 hrs apart
- Total of 2 negative specimens
- *Note: there have been reports of prolonged detection of RNA without direct correlation to viral culture
- Laboratory-confirmed COVID-19 patients who have not had any symptoms should remain in Transmission-Based Precautions until either
- Time-based strategy
- 10 days since date of first positive COVID-19 diagnostic test (assumes no developed symptoms since positive test)
- *Note: symptoms cannot be used to gauge where these individuals are in the course of their illness
- Possible that duration of viral shedding could be longer or shorter than 10 days after first positive test
- Test-based strategy
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from ≥ 2 consecutive respiratory specimens collected ≥ 24 hrs apart
- Total of 2 negative specimens
- *Note: because absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness
- There have been reports of prolonged detection of RNA without direct correlation to viral culture
- *Note:
- Detecting viral RNA via PCR does not necessarily mean that infectious virus is present
- Consider consulting with local infectious disease if suspect patients might remain infectious > 10 days (e.g., severely immunocompromised)
Related Topics
References
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Contributor(s)
- Wedro, Benjamin, MD
- Ho, Nghia, MD
- Cherian, Geo, MD
- Singh, Ajaydeep, MD
- Shaw, Iissha, PharmD Candidate
- Krivova, Irina, PharmD Candidate
- Brown, Tim, PharmD Candidate
Updated/Reviewed: November 2024