Last reviewed: 16 Mar 2021
Last updated: 15 Apr 2021
15 Apr 2021

What’s new at this update

NICE updates guidance on use of dexamethasone and IL-6 inhibitors

  • The UK National Institute for Health and Care Excellence (NICE) recommends offering dexamethasone (or a suitable alternative) to people who need supplemental oxygen to meet their prescribed oxygen saturation levels, or who have a level of hypoxia that needs supplemental oxygen but who are unable to have or tolerate it. See the Treatment algorithm for more information.

  • NICE also now recommends a single dose of tocilizumab (or sarilumab) in hospitalized patients who meet specific criteria. See the Emerging section for more information.

NIH updates guidance on use of monoclonal antibodies

  • The US National Institutes of Health guidelines panel has updated its guidance to recommend either casirivimab/imdevimab or bamlanivimab/etesevimab for the treatment of outpatients with mild to moderate disease who are at high risk of clinical progression.

  • The panel recommends against the use of monoclonal antibodies in hospitalized patients, except in the context of a clinical trial. The panel also now recommends against the use of bamlanivimab monotherapy. See the Emerging section for more information.

Janssen vaccine paused in the US

  • The Centers for Disease Control and Prevention has asked clinicians to pause administering the Janssen vaccine while it investigates the occurrence of rare but severe thrombotic events.

  • See the Prevention section for more information.

EMA reviewing new vaccine safety signals

  • The European Medicines Agency is currently reviewing cases of capillary leak syndrome associated with the AstraZeneca vaccine, and cases of unusual blood clots with thrombocytopenia with the Janssen vaccine.

  • See the Prevention section for more information.

PRINCIPLE trial reports benefit for inhaled budesonide

  • The PRINCIPLE trial has reported a 3-day median benefit in self-reported recovery for patients in the community setting who received inhaled budesonide. As a consequence, UK guidance now recommends that inhaled budesonide can be considered on a case-by-case basis in eligible patients.

  • See the Management approach section for more information.

B.1.1.7 UK variant not linked to more severe disease

  • According to two new studies, the B.1.1.7 variant does not appear to be associated with more severe disease compared with the wild-type virus.

  • See the Etiology section for more information.

com.bmj.content.model.Caption@54c4e43f[Figure caption and citation for the preceding image starts]: Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 11 April 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
  • hemoglobin disorders
  • hypertension
  • dementia
  • chronic liver disease
  • immunosuppression
  • children with certain underlying conditions
  • vitamin D deficiency
  • proton-pump inhibitor use
  • autoimmune disease
  • HIV infection
  • substance use disorders
  • 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

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.

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.

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 reviewersVIEW ALL

Professor

Division of Infectious Diseases and International Health

University of Virginia

Charlottesville

VA

Disclosures

WAP declares that he has no competing interests.

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.

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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