Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Patients with suspected or confirmed mild disease (i.e., symptomatic patients meeting the case definition for COVID-19 without evidence of hypoxia or pneumonia) and asymptomatic patients should be isolated to contain virus transmission.[2]
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, with telemedicine or remote visits as appropriate.[2][3] This decision requires careful clinical judgment and should be informed by an assessment of the patient’s home environment to ensure that: infection prevention and control measures and other requirements can be met (e.g., basic hygiene, adequate ventilation); the caregiver is able to provide care and recognize when the patient may be deteriorating; the caregiver has adequate support (e.g., food, supplies, psychological support); the support of a trained health worker is available in the community.[564] The location of care will depend on guidance from local health authorities and available resources.
Pregnant women with suspected or confirmed mild disease may not require acute care in a hospital unless there is concern for rapid deterioration or an inability to return to hospital promptly.[2]
Advise patients and household members to follow appropriate infection prevention and control measures:
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway: 10 days after positive test (asymptomatic patients); 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms (symptomatic patients).[2] The Centers for Disease Control and Prevention (CDC) recommends discontinuing home isolation once at least 10 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing home isolation once at least 10 days have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used.[593] If the patient is hospitalized, CDC guidance for discontinuing isolation is the same as for moderate disease (see below). Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 10 days in patients with milder disease who are managed in the community.[594]
Treatment recommended for ALL patients in selected patient group
Advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients ages 1 year and older) to help cough.[586] A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[601]
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.[2]
Advise patients to improve air circulation by opening a window or door (fans can spread infection and should not be used).[586]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[602]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][586] There is no evidence at present of severe adverse events in COVID-19 patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilization, long-term survival, or quality of life in patients with COVID-19.[595][596][597][598][599][600]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]
See the Emerging section for more information.
Patients with suspected or confirmed moderate disease (i.e., clinical signs of pneumonia but no signs of severe pneumonia) should be isolated to contain virus transmission.[2]
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation, with telemedicine or remote visits as appropriate, can be considered in low-risk patients. Manage patients at high risk of deterioration and pregnant women in a healthcare facility.[2][3]
Implement local infection prevention and control procedures when managing patients with COVID-19. For patients in home isolation, advise patients and household members to follow appropriate infection prevention and control measures:
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2] The Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 10 days (not severely immunocompromised) or 20 days (severely immunocompromised) have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 10 days (not severely immunocompromised) or 20 days (severely immunocompromised) have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[603] If the patient is isolated at home, CDC guidance for discontinuing isolation is the same as for mild disease (see above). Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients, and 10 days in patients with milder disease who are managed in the community. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[594]
Treatment recommended for ALL patients in selected patient group
Closely monitor patients for signs or symptoms of disease progression. If the patient is being managed at home, counsel them about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain). If the patient is being managed in hospital, monitor patients closely for signs of clinical deterioration using medical early warning scores (e.g., National Early Warning Score 2 [NEWS2]), and respond immediately with appropriate supportive care interventions.[2]
Treatment recommended for ALL patients in selected patient group
Advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients ages 1 year and older) to help cough.[586] A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[601]
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.[2]
Advise patients to improve air circulation by opening a window or door (fans can spread infection and should not be used).[586]
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.[2]
Consider treatment for olfactory dysfunction (e.g., olfactory training) if it persists beyond 2 weeks. There is no evidence to support the use of these treatments in patients with COVID-19.[602]
Treatment recommended for SOME patients in selected patient group
Consider empiric antibiotics if there is clinical suspicion of bacterial infection.[2][3] Antibiotics may also be considered in older people (particularly those in long-term care facilities) and children <5 years of age to provide empiric antibiotic treatment for possible pneumonia. The regimen should be based on the clinical diagnosis, local epidemiology and susceptibility data, and local treatment guidelines.[2]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][586] There is no evidence at present of severe adverse events in COVID-19 patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilization, long-term survival, or quality of life in patients with COVID-19.[595][596][597][598][599][600]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]
See the Emerging section for more information.
Patients with suspected or confirmed severe disease are at risk of rapid clinical deterioration and should be admitted to an appropriate healthcare facility under the guidance of a specialist team. Severe disease in adults is defined as having clinical signs of pneumonia plus at least one of the following: respiratory rate >30 breaths/minute, severe respiratory distress, or SpO₂ <90% on room air. Severe disease in children is defined as having clinical signs of pneumonia plus at least one of the following: central cyanosis or SpO₂ <90%, severe respiratory distress, general danger signs (inability to breastfeed or drink, lethargy or unconsciousness, or convulsions), or fast breathing (<2 months: ≥60 breaths per minute; 2-11 months: ≥50 breaths per minute; 1-5 years: ≥40 breaths per minute).[2]
Assess all adults for frailty on admission to hospital, irrespective of age and COVID-19 status, using the Clinical Frailty Scale (CFS). Clinical frailty scale external link opens in a new window Involve critical care teams in discussions about admission to critical care.[585] A meta-analysis found that an increase in CFS was associated with an increase in mortality (each 1-point increase in CFS was associated with a 12% increase in mortality).[684]
Implement local infection prevention and control procedures when managing patients with COVID-19.
Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as midwifery and mental health and psychosocial support. A woman-centered, respectful, skilled approach to care is recommended.[2] The multidisciplinary team should be organized as soon as possible after maternal hypoxemia occurs in order to assess fetal maturity, disease progression, and the best options for delivery.[669]
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2] The Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 20 days have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[603] Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[594]
Treatment recommended for ALL patients in selected patient group
Start supplemental oxygen therapy immediately in any patient with emergency signs (i.e., obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma and/or convulsions), or any patient without emergency signs and SpO₂ <90%.[2][3]
Target SpO₂ to ≥94% during resuscitation in adults and children with emergency signs who require emergency airway management and oxygen therapy. Once the patient is stable, a target SpO₂ >90% in children and nonpregnant adults, and ≥92% to 95% in pregnant women, is recommended. Nasal prongs or a nasal cannula are preferred in young children.[2] Some guidelines recommend that SpO₂ should be maintained no higher than 96%.[607]
Some centers may recommend different SpO₂ targets in order to support prioritization of oxygen flow for the most severely ill patients in hospital. NHS England recommends a target of 92% to 95% (or 90% to 94% if clinically appropriate), for example.[608]
Consider positioning techniques (e.g., high supported sitting, prone position), and airway clearance management to assist with secretion clearance in adults.[2] Oxygen delivery can be increased by using a nonrebreathing mask and prone positioning.[609] Consider a trial of awake prone positioning to improve oxygenation in patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation is not otherwise indicated.[3] Early self-proning of awake, nonintubated patients has been shown to improve oxygen saturation and may delay or reduce the need for intensive care.[610][611][612][613][614]
Monitor patients closely for signs of progressive acute hypoxemic respiratory failure.[2][3]
Treatment recommended for ALL patients in selected patient group
Fluids and electrolytes: use cautious fluid management in adults and children without tissue hypoperfusion and fluid responsiveness as aggressive fluid resuscitation may worsen oxygenation.[2] Correct any electrolyte or metabolic abnormalities, such as hyperglycemia or metabolic acidosis, according to local protocols.[615]
Cough: advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients ages 1 year and older) to help cough. Short-term use of a cough suppressant may be considered in select patients (e.g., if the cough is distressing to the patient) provided there are no contraindications.[586] A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.[601]
Breathlessness: keep the room cool, and encourage relaxation, breathing techniques, and changing body positions. Identify and treat any reversible causes of breathlessness (e.g., pulmonary edema). Consider a trial of oxygen, if available. Consider an opioid and benzodiazepine combination in patients with moderate to severe breathlessness or patients who are distressed.[586]
Anxiety, delirium, and agitation: identify and treat any underlying or reversible causes (e.g., offer reassurance, treat hypoxia, correct metabolic or endocrine abnormalities, address coinfections, minimize use of drugs that may cause or worsen delirium, treat substance withdrawal, maintain normal sleep cycles, treat pain or breathlessness).[2][586] Consider a benzodiazepine for the management of anxiety or agitation that does not respond to other measures. Consider haloperidol or a phenothiazine for the management of delirium.[586] Low doses of haloperidol (or another suitable antipsychotic) can also be considered for agitation.[2] Nonpharmacologic interventions are the mainstay for the management of delirium when possible, and prevention is key.[616]
Mouth care: an important part of overall patient care in hospitalized patients who are ventilated or nonventilated and those undergoing step-down or end-of-life care.[617]
Mental health symptoms: provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia or depression as appropriate.[2]
Treatment recommended for ALL patients in selected patient group
Primary options
enoxaparin: consult specialist for guidance on dose
OR
dalteparin: consult specialist for guidance on dose
Secondary options
fondaparinux: consult specialist for guidance on dose
OR
heparin: consult specialist for guidance on dose
Assess the risk of bleeding as soon as possible after admission, or by the time of the first consultant review, using a suitable risk assessment tool.[618]
Start venous thromboembolism (VTE) prophylaxis in acutely ill hospitalized adults and adolescents with COVID-19 as per the standard of care for other hospitalized patients without COVID-19, provided there are no contraindications. A COVID-19 diagnosis should not influence a pediatrician’s recommendations about VTE prophylaxis in hospitalized children. Pregnant women should be managed by a specialist.[2][3][619][620] Start as soon as possible and within 14 hours of admission, and continue for the duration of the hospital stay or 7 days, whichever is longer.[618]
Low molecular weight heparin or fondaparinux are preferred over unfractionated heparin in order to reduce patient contact.[2] The National Institute for Health and Care Excellence in the UK recommends low molecular weight heparin first-line, with fondaparinux or unfractionated heparin reserved for patients who cannot have low molecular weight heparin.[618] Unfractionated heparin is contraindicated in patients with severe thrombocytopenia. Fondaparinux is recommended in patients with a history of heparin-induced thrombocytopenia. Direct oral anticoagulants are not recommended. Mechanical thromboprophylaxis (e.g., intermittent pneumatic compression devices) is recommended if anticoagulation is contraindicated or not available.[2][620][621]
The optimal dose is unknown. Standard prophylaxis doses are recommended over intermediate- or full treatment-dose regimens.[618][620] Some clinicians are using intermediate- or full treatment-dose regimens rather than prophylactic doses as they are worried about undetected thrombi; however, this may lead to major bleeding events.[622] There are insufficient data to recommend increased anticoagulant doses for VTE prophylaxis in COVID-19 patients outside the setting of a clinical trial.[3] However, some guidelines recommend that escalated doses can be considered in critically ill patients.[619] The National Institute for Health and Care Excellence in the UK only recommends considering intermediate doses in patients who are having advanced respiratory support, and the decision should be based on multidisciplinary or senior opinion, or locally agreed protocols. Reassess VTE and bleeding risks daily in these patients.[618] NHS England recommends that therapeutic doses should not be offered unless there is a standard indication for therapeutic anticoagulation, as trials show that therapeutic doses do not improve clinical outcome of severe disease in the critical care setting.[668] Dose adjustments may be required in patients with extremes of body weight or renal impairment.[618]
For patients who are already on an anticoagulant for another condition, continue the patient’s current therapeutic dose unless contraindicated by a change in clinical circumstances. Consider switching to low molecular weight heparin as the preferred option for venous thromboembolism prophylaxis if the patient’s clinical condition is deteriorating and the patient is not currently on low molecular weight heparin.[618]
Monitor patients for signs and symptoms suggestive of thromboembolism and proceed with appropriate diagnostic and management pathways if clinically suspected.[2] If the patient’s clinical condition changes, assess the risk of VTE, reassess the bleeding risk, and review VTE prophylaxis.[618]
Routine post-discharge VTE prophylaxis is not generally recommended, except in certain high-risk patients.[3][619][620] Ensure patients who require VTE prophylaxis after discharge are able to use it correctly or have arrangements made for someone to help them.[618]
There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulation in hospitalized patients with COVID-19.[625] A retrospective analysis of over 4000 patients found that anticoagulation was associated with lower mortality and intubation among hospitalized COVID-19 patients. Therapeutic anticoagulation was associated with lower mortality compared with prophylactic anticoagulation, but the difference was not statistically significant.[626] Clinicians should rely on pre-COVID-19 evidence-based principles of anticoagulation management combined with rational approaches to address clinical challenges.[619]
Treatment recommended for ALL patients in selected patient group
Monitor patients closely for signs of clinical deterioration, and respond immediately with appropriate supportive care interventions.[2]
Treatment recommended for SOME patients in selected patient group
Consider empiric antibiotics if there is clinical suspicion of bacterial infection. Give within 1 hour of initial assessment for patients with suspected sepsis or if the patient meets high-risk criteria (or within 4 hours of establishing a diagnosis of pneumonia); do not wait for microbiology results. Base the regimen on the clinical diagnosis (e.g., community-acquired pneumonia, hospital-acquired pneumonia, sepsis), local epidemiology and susceptibility data, and local treatment guidelines.[2][3][541]
Some guidelines recommend empiric antibiotics for bacterial pathogens in all patients with community-acquired pneumonia without confirmed COVID-19. It is likely that the bacterial pathogens in patients with COVID-19 and pneumonia are the same as in previous patients with community-acquired pneumonia, and therefore empiric antimicrobial recommendations should be the same.[542] However, the National Institute for Health and Care Excellence in the UK recommends that it is reasonable not to start empiric antimicrobials if you are confident that the clinical features are typical for COVID-19.[541] There is insufficient evidence to recommend empiric broad-spectrum antimicrobials in the absence of another indication.[3]
Some patients may require continued antibiotic therapy once COVID-19 has been confirmed depending on the clinical circumstances (e.g., clinical or microbiologic evidence of bacterial infection regardless of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] test results, SARS-CoV-2 test result is positive but clinical features are not typical for COVID-19). In these circumstances, review antibiotic choice based on microbiology results and switch to a narrower-spectrum antibiotic if appropriate, review intravenous antibiotic use within 48 hours and consider switching to oral therapy, and give for a total of 5 days unless there is a clear indication to continue.[541]
Reassess antibiotic use daily. De-escalate empiric therapy on the basis of microbiology results and clinical judgment. Regularly review the possibility of switching from intravenous to oral therapy. Duration of treatment should be as short as possible (e.g., 5 to 7 days). Antibiotic stewardship programs should be in place.[2]
Treatment recommended for SOME patients in selected patient group
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
Secondary options
prednisone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
The World Health Organization (WHO) strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with severe COVID-19. This recommendation is based on two meta-analyses that pooled data from eight randomized trials (over 7000 patients), including the UK RECOVERY trial. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical COVID-19. They also probably reduce the need for invasive ventilation. There is no evidence directly comparing dexamethasone and hydrocortisone. The harms of treatment in this context are considered to be minor. It is unclear whether these recommendations can be applied to children or those who are immunocompromised.[587][628][629] There is also evidence that corticosteroids probably reduce the length of intensive care unit stay (low certainty), and increase ventilator-free days (moderate certainty).[630][685]
In the UK, the National Institute for Health and Care Excellence recommends dexamethasone or hydrocortisone in patients with severe COVID-19 (in line with WHO guidance). The marketing authorizations cover this indication in the UK.[585]
NICE: COVID-19 prescribing brief – corticosteroids external link opens in a new window
In Europe, the European Medicines Agency has endorsed the use of dexamethasone for patients with severe disease who require oxygen therapy or mechanical ventilation.[632]
In the US, the National Institutes of Health guidelines panel recommends dexamethasone, either alone or in combination with remdesivir (see the Emerging section for information on remdesivir), in hospitalized patients who require supplemental oxygen. The panel recommends against using dexamethasone in patients who do not require supplemental oxygen. Alternative corticosteroids may be used in situations where dexamethasone is not available.[3] The Infectious Diseases Society of America supports the use of dexamethasone in hospitalized patients with severe disease.[633]
Monitor patients for adverse effects (e.g., hyperglycemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3] Follow local policies on gastroprotection during corticosteroid treatment. Clinically significant interactions between remdesivir and corticosteroids are unlikely; however, lopinavir/ritonavir may increase hydrocortisone concentrations.[585]
Treatment should stop if the person is discharged from hospital before the 10-day course is completed.[585]
Treatment recommended for SOME patients in selected patient group
Treat laboratory-confirmed coinfections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2] The treatment of influenza is the same in all patients regardless of SARS-CoV-2 coinfection. Start empiric treatment with oseltamivir in hospitalized patients who are suspected of having either or both infections as soon as possible without waiting for influenza test results. Antiviral therapy can be stopped once influenza has been ruled out.[3]
Treatment recommended for SOME patients in selected patient group
Primary options
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally (immediate-release) every 4-6 hours when required, maximum 4000 mg/day
OR
ibuprofen: children 6 months to 11 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day
Acetaminophen or ibuprofen are recommended.[2][607] There is no evidence at present of severe adverse events in COVID-19 patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilization, long-term survival, or quality of life in patients with COVID-19.[595][596][597][598][599][600]
Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. It is not recommended in pregnant women (especially in the third trimester) or children <6 months of age (age cut-offs vary by country).
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]
See the Emerging section for more information.
Treatment recommended for SOME patients in selected patient group
Routinely assess older patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]
Treatment recommended for SOME patients in selected patient group
Palliative care interventions should be made accessible at each institution that provides care for patients with COVID-19. Identify whether the patient has an advance care plan and respect the patient’s priorities and preferences when formulating the patient’s care plan.[2] Follow local palliative care guidelines.
Patients with critical disease (i.e., presence of acute respiratory distress syndrome, sepsis, or septic shock) should be admitted or transferred to an intensive/critical care unit under the guidance of a specialist team.[2]
Discuss the risks, benefits, and potential outcomes of treatment options with patients and their families, and allow them to express preferences about their management. Take their wishes and expectations into account when considering the ceiling of treatment. Use decision support tools if available. Put treatment escalation plans in place, and discuss any existing advance care plans or advance decisions to refuse treatment with patients who have preexisting advanced comorbidities.[586]
Implement local infection prevention and control procedures when managing patients with COVID-19.
Pregnant women should be managed by a multidisciplinary team, including obstetric, perinatal, neonatal, and intensive care specialists, as well as midwifery and mental health and psychosocial support. A woman-centered, respectful, skilled approach to care is recommended.[2] The multidisciplinary team should be organized as soon as possible after maternal hypoxemia occurs in order to assess fetal maturity, disease progression, and the best options for delivery.[669]
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.[2] The Centers for Disease Control and Prevention (CDC) recommends discontinuing isolation once at least 20 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing isolation once at least 20 days have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. A symptom-based strategy is preferred in these patients.[603] Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the isolation period is 14 days from a positive test in hospitalized patients. Immunocompetent patients who tested positive on RT-PCR and have completed their 14-day isolation period are exempt from testing prior to hospital discharge if they are within 90 days from their initial illness onset or test, unless they develop new symptoms.[594]
Treatment recommended for ALL patients in selected patient group
Consider fluid and electrolyte management, antimicrobial treatment, venous thromboembolism prophylaxis, and symptom management as appropriate. See Severe COVID-19 above for more detailed information.
As with severe disease, guidelines recommend low molecular weight heparin as the preferred option for venous thromboembolism prophylaxis. However, unfractionated heparin is preferred over fondaparinux in critically ill patients if low molecular weight heparin as the preferred option for venous thromboembolism prophylaxis cannot be used.[620] Some guidelines recommend that escalated doses can be considered in critically ill patients.[619][623] The National Institute for Health and Care Excellence in the UK recommends considering intermediate doses in patients who are having advanced respiratory support, and the decision should be based on multidisciplinary or senior opinion, or locally agreed protocols. Reassess venous thromboembolism and bleeding risks daily in these patients.[618] NHS England recommends that therapeutic doses should not be offered unless there is a standard indication for therapeutic anticoagulation, as trials show that therapeutic doses do not improve clinical outcome of severe disease in the critical care setting.[668] Dose adjustments may be required in patients with extremes of body weight or renal impairment.[618]
Follow local guidelines for the management of pain, sedation, and delirium.[3]
Implement standard interventions to prevent complications associated with critical illness.[2]
Treatment recommended for ALL patients in selected patient group
Consider a trial of high-flow nasal oxygen (HFNO) or noninvasive ventilation (e.g., continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) in selected patients with mild acute respiratory distress syndrome.[2]
Airborne precautions are recommended for these interventions (including bubble CPAP) due to uncertainty about the potential for aerosolization.[2]
Patients with hypercapnia, hemodynamic instability, multi-organ failure, or abnormal mental status should generally not receive HFNO, although emerging data suggest that it may be safe in patients with mild to moderate and nonworsening hypercapnia. Patients with hypoxemic respiratory failure and hemodynamic instability, multi-organ failure, or abnormal mental status should not receive these treatments in place of other options such as invasive ventilation.[2]
There is ongoing debate about the optimal mode of respiratory support before mechanical ventilation.[638] NHS England recommends CPAP as the preferred form of noninvasive ventilation in patients with hypoxemic (type 1) respiratory failure. It doesn't advocate the use of HFNO based on a lack of efficacy, oxygen use (HFNO can place a strain on oxygen supplies with the risk of site supply failure), and infection spread.[639] Other guidelines recommend HFNO over noninvasive ventilation, unless HFNO is not available.[3][607] Despite the trend to avoid HFNO, it has been shown to have a similar risk of aerosol generation to standard oxygen masks.[640]
Early CPAP may provide a bridge to invasive mechanical ventilation. Reserve the use of BiPAP for patients with hypercapnic acute on chronic ventilatory failure (type 2 respiratory failure).[639]
Monitor patients closely for acute deterioration. If patients do not improve after a short trial of these interventions, they require urgent endotracheal intubation.[2][607]
Treatment recommended for ALL patients in selected patient group
Consider endotracheal intubation and mechanical ventilation in patients who are acutely deteriorating despite advanced oxygen/noninvasive ventilatory support measures.[2][3]
Endotracheal intubation should be performed by an experienced provider using airborne precautions.[2] Intubation by video laryngoscopy is recommended if possible.[3] Young children, or adults who are obese or pregnant, may desaturate quickly during intubation and therefore require preoxygenation with 100% fraction of inspired oxygen (FiO₂) for 5 minutes.[2]
Mechanically ventilated patients with acute respiratory distress syndrome (ARDS) should receive a lung-protective, low tidal volume/low inspiratory pressure ventilation strategy (lower targets are recommended in children). A higher positive end-expiratory pressure (PEEP) strategy is preferred over a lower PEEP strategy in moderate to severe ARDS. However, individualization of PEEP, where the patient is monitored for beneficial or harmful effects and driving pressure during titration with consideration of the risks and benefits of PEEP titration, is recommended.[2][3][607] NHS England recommends a low PEEP strategy in patients with normal compliance where recruitment may not be required.[648]
Although some patients with COVID-19 pneumonia meet the criteria for ARDS, there is some discussion about whether COVID-19 pneumonia is its own specific disease with atypical phenotypes. Anecdotal evidence suggests that the main characteristic of the atypical presentation is the dissociation between well-preserved lung mechanics and the severity of hypoxemia.[649][650][651][652][653][654] However, this approach has been criticized.[655][656] It has been argued that an evidence-based approach extrapolating data from ARDS not related to COVID-19 is the most reasonable approach for intensive care of COVID-19 patients.[657] As a consequence of this, some clinicians have warned that protocol-driven ventilator use may be causing lung injury in some patients, and that ventilator settings should be based on physiologic findings rather than using standard protocols. High PEEP may have a detrimental effect on patients with normal compliance.[649] PEEP should always be carefully titrated.[609]
Consider prone ventilation in patients with severe ARDS for 12 to 16 hours per day. Pregnant women in the third trimester may benefit from being placed in the lateral decubitus position. Caution is required in children.[2][3][607] Longer durations may be feasible in some patients.[658]
Lung recruitment maneuvers are suggested, but staircase recruitment maneuvers are not recommended.[3][607]
Treatment recommended for SOME patients in selected patient group
Consider extracorporeal membrane oxygenation (ECMO) according to availability and expertise if the above methods fail.[2][607][662][663] ECMO is not suitable for all patients, and only those who meet certain inclusion criteria may be considered for ECMO.[664]
There is insufficient evidence to recommend either for or against the routine use of ECMO.[3]
The estimated 60-day survival rate of ECMO-rescued patients with COVID-19 (31%) was similar to that of previous studies of ECMO for severe ARDS.[665]
An international cohort study of 1035 patients found that both the estimated mortality 90 days after ECMO initiation and mortality in those who achieved a final outcome of death or discharge were <40%, consistent with previously reported survival rates in acute hypoxemic respiratory failure.[666]
Single-access, dual-stage venovenous ECMO with early extubation appears to be safe and effective in patients with COVID-19 respiratory failure.[667]
Treatment recommended for SOME patients in selected patient group
The management of sepsis and septic shock in patients with COVID-19 is beyond the scope of this topic. See the Complications section.
Treatment recommended for SOME patients in selected patient group
Primary options
dexamethasone: adults: 6 mg orally/intravenously once daily for 7-10 days
OR
hydrocortisone: adults: 50 mg orally/intravenously every 8 hours for 7-10 days
MoreSecondary options
prednisone: adults: 40 mg/day orally given in 1-2 divided doses for 7-10 days
OR
methylprednisolone: adults: 32 mg/day orally/intravenously given in 1-2 divided doses for 7-10 days
The World Health Organization (WHO) strongly recommends systemic corticosteroid therapy (low-dose intravenous or oral dexamethasone or hydrocortisone) for 7 to 10 days in adults with critical COVID-19. This recommendation is based on two meta-analyses that pooled data from eight randomized trials (over 7000 patients), including the UK RECOVERY trial. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical COVID-19. They also probably reduce the need for invasive ventilation. There is no evidence directly comparing dexamethasone and hydrocortisone. The harms of treatment in this context are considered to be minor. It is unclear whether these recommendations can be applied to children or those who are immunocompromised.[587][628][629] There is also evidence that corticosteroids probably reduce the length of intensive care unit stay (low certainty), and increase ventilator-free days (moderate certainty).[630][685]
In the UK, the National Institute for Health and Care Excellence recommends dexamethasone or hydrocortisone in patients with critical COVID-19 (in line with WHO guidance). The marketing authorizations cover this indication in the UK.[585]
NICE: COVID-19 prescribing brief – corticosteroids external link opens in a new window
In Europe, the European Medicines Agency has endorsed the use of dexamethasone for patients with severe disease who require oxygen therapy or mechanical ventilation.[632]
In the US, the National Institutes of Health guidelines panel recommends using dexamethasone, either alone or in combination with remdesivir (see the Emerging section for information on remdesivir), in hospitalized patients who require high-flow oxygen or noninvasive ventilation. The panel recommends dexamethasone alone in patients on mechanical ventilation or extracorporeal membrane oxygenation. Alternative corticosteroids may be used in situations where dexamethasone is not available.[3] The Infectious Diseases Society of America supports the use of dexamethasone in hospitalized patients with severe disease.[633]
Monitor patients for adverse effects (e.g., hyperglycemia, secondary infections, psychiatric effects, reactivation of latent infections) and assess for drug-drug interactions.[3] Follow local policies on gastroprotection during corticosteroid treatment. Clinically significant interactions between remdesivir and corticosteroids are unlikely; however, lopinavir/ritonavir may increase hydrocortisone concentrations.[585]
Treatment should stop if the person is discharged from hospital before the 10-day course is completed.[585]
Treatment recommended for SOME patients in selected patient group
Treat laboratory-confirmed coinfections (e.g., malaria, tuberculosis, influenza) as appropriate according to local protocols.[2] The treatment of influenza is the same in all patients regardless of SARS-CoV-2 coinfection. Start empiric treatment with oseltamivir in hospitalized patients who are suspected of having either or both infections as soon as possible without waiting for influenza test results. Antiviral therapy can be stopped once influenza has been ruled out.[3]
Treatment recommended for SOME patients in selected patient group
Consider appropriate experimental or emerging therapies.
Antiviral therapies will have a greater effect early in the course of the disease, whereas immunosuppressive/anti-inflammatory therapies are likely to have a greater effect later in the course of the disease.[3]
See the Emerging section for more information.
Treatment recommended for SOME patients in selected patient group
Routinely assess intensive care patients for mobility, functional swallow, cognitive impairment, and mental health concerns, and based on that assessment determine whether the patient is ready for discharge, and whether the patient has any rehabilitation and follow-up requirements.[2]
Treatment recommended for SOME patients in selected patient group
Palliative care interventions should be made accessible at each institution that provides care for patients with COVID-19. Identify whether the patient has an advance care plan and respect the patient’s priorities and preferences when formulating the patient’s care plan.[2] Follow local palliative care guidelines.
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