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Management of Persons with COVID-19

Last Updated: April 21, 2020

Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can experience a range of clinical manifestations, from no symptoms to critical illness. This section discusses the clinical management of patients according to the severity of their illness. Currently, no Food and Drug Administration (FDA)-approved drugs exist to specifically treat patients with COVID-19. Chloroquine and hydroxychloroquine, which are not FDA approved for COVID-19, are available from the Strategic National Stockpile for hospitalized adults and adolescents (weighing ≥50 kg) under an Emergency Use Authorization. An array of drugs approved for other indications, as well as multiple investigational agents, are being studied for the treatment of COVID-19 in several hundred clinical trials around the globe. Some drugs can be accessed through expanded access or compassionate use mechanisms. Available clinical data for these drugs under investigation are discussed in the Antiviral Therapy and Immune-Based Therapy sections of these Guidelines. As noted in that section, no drug has been proven to be safe and effective for the treatment of COVID-19.

In general, patients with COVID-19 can be grouped into the following illness categories:

  • Asymptomatic or Presymptomatic Infection: Individuals who test positive for SARS-CoV-2 but have no symptoms
  • Mild Illness: Individuals who have any of various signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal imaging
  • Moderate Illness: Individuals who have evidence of lower respiratory disease by clinical assessment or imaging and a saturation of oxygen (SpO2) >93% on room air at sea level.
  • Severe Illness: Individuals who have respiratory frequency >30 breaths per minute, SpO2 ≤93% on room air at sea level, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung infiltrates >50%
  • Critical Illness: Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction

Asymptomatic or Presymptomatic Infection

Asymptomatic infection can occur, although the percentage of patients who remain truly asymptomatic for the course of their infection is unknown. It is unclear at present what percentage of individuals who present with asymptomatic infection may progress to clinical disease. Some asymptomatic individuals have been reported to have objective radiographic findings consistent with COVID-19 pneumonia. Eventually, the availability of widespread testing for SARS-CoV-2 and the development of serologic assays for antibodies to the virus will help determine the true prevalence of asymptomatic and presymptomatic infections.1

Persons who test positive for SARS-CoV-2 and who are asymptomatic should self-isolate. If they remain asymptomatic, they can discontinue isolation 7 days after the date of their first positive SARS-CoV-2 test.2 Individuals who become symptomatic should contact their health care provider for further guidance. Health care workers who test positive and are asymptomatic may obtain additional guidance from their occupational health service. See the Centers for Disease Control and Prevention COVID-19 website for detailed information.

The Panel recommends no additional laboratory testing and no specific treatment for persons with suspected or confirmed asymptomatic or presymptomatic SARS-CoV-2 infection (AIII).

Mild Illness

Patients may have mild illness defined by any of various signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath or dyspnea or abnormal imaging. Most mildly ill patients can be managed in an ambulatory setting or at home through telemedicine or remote visits.

All patients with symptomatic COVID-19 and risk factors for severe disease should be closely monitored. In some patients the clinical course may rapidly progress.3, 4

No specific laboratory evaluations are indicated in otherwise healthy patients with mild COVID-19 disease.

There are insufficient data to recommend either for or against any antiviral or immunomodulatory therapy in patients with COVID-19 with mild illness (AIII).

Moderate Illness

Moderate COVID-19 illness is defined as evidence of lower respiratory disease by clinical assessment or imaging with SpO2 >93% on room air at sea level. Given that pulmonary disease can rapidly progress in patients with COVID-19, patients with moderate COVID-19 should be admitted to a health care facility for close observation. If bacterial pneumonia or sepsis is strongly suspected, administer empiric antibiotic treatment for community-acquired pneumonia, re-evaluate daily, and if there is no evidence of bacterial infection, de-escalate or stop antibiotics.

Most patients with moderate to severe illness will require hospitalization. Hospital infection prevention and control measures include use of personal protective equipment (PPE) for droplet and contact precautions (e.g., masks, face shields, gloves, gowns), including eye protection (e.g., face shields or goggles) and single-patient dedicated medical equipment (e.g., stethoscopes, blood pressure cuffs, thermometers).5,6 The number of individuals and providers entering the room of a patient with COVID-19 should be limited. If necessary, confirmed COVID-19 patients may be cohorted in the same room. If available, airborne infection isolation rooms (AIIRs) should be used for patients who will be undergoing any aerosol-generating procedures. During these procedures, all staff should wear N95 respirators or powered, air-purifying respirators (PAPRs) rather than a surgical mask.7

The optimal pulmonary imaging technique for people with COVID-19 is yet to be defined. Initial evaluation may include chest x-ray, ultrasound, or if indicated, CT. Electrocardiogram (ECG) should be performed if indicated. Laboratory testing includes a complete blood count (CBC) with differential and a metabolic profile, including liver and renal function tests. Measurements of inflammatory markers such as C-reactive protein (CRP), D-dimer, and ferritin, while not part of standard care, may have prognostic value.

There are insufficient data for the Panel to recommend either for or against any antiviral or immunomodulatory therapy in patients with COVID-19 with moderate illness (AIII).

Clinicians can refer to the Antiviral Therapy and Immune-Based Therapy sections and Tables 2a and 3a of these guidelines to review the available clinical data regarding investigational drugs being evaluated for treatment of this disease.

Severe Illness

Patients with COVID-19 are considered to have severe illness if they have SpO2 ≤93% on room air at sea level, respiratory rate >30, PaO2/FiO2 <300, or lung infiltrates >50%. These patients may experience rapid clinical deterioration and will likely need to undergo aerosol-generating procedures. They should be placed in AIIRs, if available. Administer oxygen therapy immediately using nasal cannula or high-flow oxygen.

If secondary bacterial pneumonia or sepsis is suspected, administer empiric antibiotics, re-evaluate daily, and if there is no evidence of bacterial infection, de-escalate or stop antibiotics.

Evaluation should include pulmonary imaging (chest x-ray, ultrasound, or if indicated, CT) and ECG, if indicated. Laboratory evaluation includes CBC with differential and metabolic profile, including liver and renal function tests. Measurements of inflammatory markers such as CRP, D-dimer, and ferritin, while not part of standard care, may have prognostic value.

There are insufficient data for the Panel to recommend either for or against any antiviral or immunomodulatory therapy in patients with COVID-19 with severe illness (AIII).

Clinicians can refer to the Antiviral Therapy and Immune-Based Therapy sections and Tables 2a and 3a of these guidelines to review the available clinical data regarding drugs being evaluated for treatment of this disease.

Critical Illness

(For additional details, see Care of Critically Ill Patients with COVID-19.)

COVID-19 is primarily a pulmonary disease. Severe cases may be associated with acute respiratory distress syndrome (ARDS), septic shock that may represent virus-induced distributive shock, cardiac dysfunction, elevations in multiple inflammatory cytokines that provoke a cytokine storm, and/or exacerbation of underlying co-morbidities. In addition to pulmonary disease, patients with COVID-19 may also experience cardiac, hepatic, renal, and central nervous system disease.

Since patients with critical illness are likely to undergo aerosol-generating procedures, they should be placed in AIIRs when available.

Most of the recommendations for the management of critically ill patients with COVID-19 are extrapolated from experience with other life-threatening infections.8 Currently, there is limited information to suggest that the critical care management of patients with COVID-19 should differ substantially from the management of other critically ill patients, although special precautions to prevent environmental contamination by SARS-CoV-2 is warranted.

The Surviving Sepsis Campaign (SSC), an initiative supported by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, issued Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) in March 2020.8 The Panel relied heavily on the SSC guidelines in making the recommendations in these Treatment Guidelines and gratefully acknowledges the work of the SSC COVID-19 Guidelines Panel.

As with any patient in the intensive care unit (ICU), successful clinical management of a patient with COVID-19 depends on attention to the primary process leading to the ICU admission, but also to other comorbidities and nosocomial complications.

There are insufficient data for the Panel to recommend either for or against any antiviral or immunomodulatory therapy in critically ill patients with COVID-19 (AIII).

Clinicians can refer to the Antiviral Therapy and Immune-Based Therapy sections and Tables 2a and 3a of these guidelines to review the available clinical data regarding drugs being evaluated for treatment of this disease.

References

  1. Wang Y, Liu Y, Liu L, Wang X, Luo N, Ling L. Clinical outcome of 55 asymptomatic cases at the time of hospital admission infected with SARS-coronavirus-2 in Shenzhen, China. J Infect Dis. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32179910.
  2. Centers for Disease Control and Prevention. Discontinuation of isolation for persons with COVID-19 not in healthcare settings (interim guidance). 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html. Accessed April 8, 2020.
  3. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32109013.
  4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31986264.
  5. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed April 8, 2020.
  6. Centers for Disease Control and Prevention. Strategies to optimize the supply of PPE and equipment. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Accessed April 8, 2020.
  7. Centers for Disease Control and Prevention. Approved respirator standards. 2006. Available at: https://www.cdc.gov/niosh/npptl/standardsdev/cbrn/papr/default.html. Accessed April 8, 2020.
  8. Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32224769.