Mild suspected or confirmed COVID-19:
- Patients with mild COVID-19 should not require hospitalization, unless there is a clinical concern for rapid deterioration, significant underlying co-morbidities, extenuating sociodemographic circumstances, or an inability to return promptly to hospital.
- Patients with mild COVID-19 and their caregivers should be provided with information on symptom management and informed of the signs and symptoms of complications that should prompt medical re-evaluation.
Moderate suspected or confirmed COVID-19 - i.e. clinical signs of pneumonia, SpO2 ≥ 90% on room air, but no signs of severe pneumonia:
- Patients with moderate COVID-19 who are not determined to be at high risk of deterioration may not require hospitalization.
- Patients with moderate COVID-19 should self-monitor and be counseled along with their caregivers about the signs and symptoms of complications that should prompt medical re-evaluation.
Severe suspected or confirmed COVID-19 - defined by the IDSA as SpO2 <94% on room air:
- Patients with severe COVID-19 and respiratory distress, hypoxaemia or shock should receive supplemental oxygen therapy immediately with target saturations of > 94% SpO2 during resuscitation. Patients with severe illness should be closely monitored for signs of clinical deterioration, specifically rapidly progressive respiratory failure or shock.
- In patients with severe COVID-19 requiring supplemental oxygen, mechanical ventilation, or extracorporeal mechanical oxygenation (ECMO), clinicians should strongly consider offering:
- dexamethasone 6 mg IV or PO daily for 10 days, or until discharge if earlier (or equivalent glucocorticoid dose: methylprednisolone 32mg, prednisone 40mg). [N Engl J Med 2020 Jul 17. doi:10.1056/NEJMoa2021436]
NB: Glucocorticoids are not recommended in patients who do not have hypoxemia requiring supplemental oxygen: no benefit and possible harm.
The use of experimental treatments for patients with COVID-19 should occur within the context of controlled clinical trials wherever possible, given the currently available limited therapeutic options for which evidence-based data are available.
- Remdesivir - At this time, remdesivir is available in very limited quantities, and currently is being made available in AHS only to patients enrolled in the CATCO Trial (A Multi-centre, Adaptive, Randomized, Open-label, Controlled Clinical Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Patients [in conjunction with the Public Health emergency SOLIDARITY trial through the World Health Organization]). This position will be reconsidered with evolving evidence of remdesivir benefit, and when a sustainable supply of remdesivir can be confirmed.
- Consideration of all other investigational antivirals or immunomodulators (e.g. tocilizumab, ritonavir/lopinavir, famotidine, and convalescent plasma) should be only under ethics-approved, controlled trials.
- The use of hydroxychloroquine, or any hydroxychloroquine combinations (e.g. hydroxychloroquine plus azithromycin) are not recommended as a treatment in patients with COVID-19.
- For those patients with suspected or confirmed mild to moderate COVID-19, antibiotics should not be routinely prescribed unless there is clinical suspicion of a bacterial infection.
- For those patients with suspected or confirmed severe COVID-19, empiric antibacterial agents should be considered to treat all likely pathogens causing severe acute respiratory bacterial infection and sepsis as soon as possible, and optimally within 1 hour of initial patient assessment for patients with sepsis. Empiric antibiotic treatment should be based on the working clinical diagnosis (e.g., community-acquired pneumonia, health care-associated pneumonia, or sepsis), local epidemiology, and susceptibility data.
- Use of antibacterial therapy should be judicious with a reassessment after 3 days for de-escalation and/or optimization of therapy, in accordance with the principles of stewardship, after review of the clinical status, laboratory and radiologic findings, and culture and susceptibility results.
- Empiric management of patients with severe pneumonia while COVID-19 is being confirmed and bacterial infection excluded, and management of potential bacterial superinfection are available in CAP, HAP, or VAP.