Last reviewed: 4 Jul 2021
Last updated: 22 Jul 2021
22 Jul 2021

What’s new at this update

WHO recommends IL-6 inhibitors for severe or critical disease

  • The World Health Organization strongly recommends IL-6 inhibitors (tocilizumab or sarilumab) in patients with severe or critical disease in the most recent update to its COVID-19 therapeutics living guideline.

  • The recommendation is based on high-certainty evidence that shows IL-6 inhibitors reduce mortality and the need for mechanical ventilation in these patients.

  • See the Treatment algorithm section for more information.

EMA warns of possible link between AstraZeneca vaccine and Guillain-Barre syndrome

  • The European Medicines Agency’s safety committee has recommended a change to the product information of the AstraZeneca vaccine to include a warning about cases of Guillain-Barre syndrome reported following vaccination. At this stage the available data neither confirm nor rule out a possible association with the vaccine.

  • The UK’s Medicines and Healthcare products Regulatory Agency is also reviewing these cases to assess, and based on the available evidence at this stage, the agency is not able to confirm or rule out a causal relationship.

  • See the Prevention section for more information.

EMA warns of link between mRNA vaccines and myocarditis/pericarditis

  • The European Medicines Agency’s safety committee has concluded that myocarditis and pericarditis can occur in very rare cases following vaccination with mRNA vaccines. The committee is recommending listing myocarditis and pericarditis as adverse effects in the product information, as well as a warning for healthcare professionals to be alert for signs and symptoms.

  • See the Prevention section for more information.

US guideline currently recommends against use of bamlanivimab/etesevimab

  • The US National Institutes of Health guidelines panel has updated its guidance to now recommend against the use of bamlanivimab/etesevimab at this time due to circulation of variants of concern, which have reduced susceptibility to this treatment.

  • See the Emerging section for more information.

com.bmj.content.model.Caption@6b17f2f3[Figure caption and citation for the preceding image starts]: Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 18 July 2021World Health Organization [Citation ends].

See Epidemiology

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Summary

Definition

History and exam

Key diagnostic factors

  • fever
  • cough
  • dyspnea
  • altered sense of smell/taste

Other diagnostic factors

  • fatigue
  • myalgia or arthralgia
  • sputum production/expectoration
  • chest tightness
  • gastrointestinal symptoms
  • sore throat
  • headache
  • dizziness
  • neurologic symptoms
  • ocular symptoms
  • rhinorrhea/nasal congestion
  • audio-vestibular symptoms
  • chest pain
  • cutaneous symptoms
  • lower urinary tract symptoms
  • hemoptysis
  • bronchial breath sounds
  • tachypnea
  • tachycardia
  • cyanosis
  • crackles/rales on auscultation

Risk factors

  • contact with probable or confirmed case
  • residence/work/travel in location with high risk of transmission
  • older age
  • male sex
  • ethnicity
  • residence in a long-term care facility
  • presence of comorbidities
  • obesity
  • cardiovascular disease
  • diabetes
  • chronic respiratory disease
  • chronic kidney disease
  • pregnancy
  • smoking
  • malignancy
  • cerebrovascular disease
  • solid organ or blood stem cell transplant
  • Down syndrome or learning disability
  • hemoglobin disorders
  • hypertension
  • dementia
  • immunosuppression
  • HIV infection
  • substance use disorders
  • children with certain underlying conditions
  • chronic liver disease
  • vitamin D deficiency
  • proton-pump inhibitor use
  • autoimmune disease
  • Parkinson disease
  • physical inactivity
  • dyslipidemia
  • surgery
  • blood groups A and B
  • gut dysbiosis
  • environmental factors

Diagnostic investigations

1st investigations to order

  • real-time reverse transcription polymerase chain reaction (RT-PCR)
  • pulse oximetry
  • ABG
  • CBC
  • comprehensive metabolic panel
  • blood glucose level
  • coagulation screen
  • cardiac biomarkers
  • serum C-reactive protein
  • serum erythrocyte sedimentation rate
  • serum lactate dehydrogenase
  • serum interleukin-6 level
  • serum procalcitonin
  • serum ferritin level
  • serum amyloid A level
  • serum creatine kinase and myoglobin
  • blood and sputum cultures
  • chest x-ray

Investigations to consider

  • computed tomography (CT) chest
  • serology
  • antigen test

Emerging tests

  • reverse transcription loop-mediated isothermal amplification (RT-LAMP)
  • lung ultrasound
  • calprotectin

Treatment algorithm

Contributors

Authors

Nicholas J. Beeching, MA, BM BCh, FRCP, FRACP, FFTM RCPS (Glasg), FESCMID, DCH, DTM&H

Consultant and Emeritus Professor of Tropical and Infectious Diseases

Royal Liverpool University Hospital and Liverpool School of Tropical Medicine

Liverpool

UK

Disclosures

NJB is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.

Tom E. Fletcher, MBE, PhD, MBChB, MRCP, DTM&H

Senior Clinical Lecturer and Defence Consultant in Infectious Diseases

Royal Liverpool University Hospital and Liverpool School of Tropical Medicine

Liverpool

UK

Disclosures

TEF is a consultant/expert panel member to the World Health Organization, and is funded by the UK Surgeon General, the NHS, and Liverpool School of Tropical Medicine. TEF is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. He has received research grants from the Wellcome Trust, Medical Research Council, and the UK Public Health Rapid Support Team (UK-PHRST). The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.

Robert Fowler, MDCM, MS (Epi), FRCP(C)

H. Barrie Fairley Professor of Critical Care

University Health Network and Interdepartmental Division of Critical Care Medicine

Director

Clinical Epidemiology and Health Care Research

Institute of Health Policy, Management and Evaluation

Dalla Lana School of Public Health

University of Toronto

Chief

Tory Trauma Program

Sunnybrook Hospital

Toronto

Canada

Disclosures

RF declares that he has no competing interests.

Peer reviewers

William A. Petri, Jr., MD, PhD

Professor

Division of Infectious Diseases and International Health

University of Virginia

Charlottesville

VA

Disclosures

WAP declares that he has no competing interests.

Xin Zhang, MD, PhD

Attending Physician

The Fifth Medical Center of PLA General Hospital

Clinical Division and Research Center of Infectious Disease

Beijing

China

Disclosures

XZ declares that he has no competing interests.

Ran Nir-Paz, MD

Associate Professor in Medicine

Department of Clinical Microbiology and Infectious Diseases

Hadassah Hebrew University Medical Center

Jerusalem

Israel

Disclosures

RNP has received research grants from US-Israel Binational Science Foundation, Hebrew University, Rosetrees Trust, and SpeeDx. He is chair of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycoplasma and Chlamydia Infections (ESGMAC). RNP is a consultant for and has stocks in eDAS Healthcare. He is also chairperson of the Israeli Society for Infectious Diseases guidelines committee.

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