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.
Remdesivir is approved for use in adult hospitalized patients with COVID-19 pneumonia but not on mechanical ventilation. Patients can be given remdesivir if they are acutely ill from COVID-19, or if they are severely immunocompromised.
- Tocilizumab is approved for use in patients with severe COVID-19 pneumonia. To be eligible, patients must:
- have been admitted to hospital for COVID-19 pneumonia 7 or fewer days ago, or have developed symptoms from hospital-acquired COVID-19 pneumonia 7 or fewer days ago.
- have significant progressive respiratory failure due to COVID-19 pneumonia that requires they receive ventilation (invasive or non-invasive) or supplemental oxygen to achieve a minimum SpO2 of 90%. Supplemental oxygen is defined as heated high flow oxygen with FiO2 > 0.5, nasal prong delivered oxygen at a rate of 6 L/minute, or mask delivered oxygen with FiO2 > 0.5.
Tocilizumab must be initiated within 24 hours of initiation of mechanical ventilation or, if not mechanically ventilated, as soon as possible.
Tocilizumab is restricted for this indication to one dose per patient per hospitalization, dosed as follows:
< 40 kg: 8 mg/kg
> 40 kg: 400 mg
- Bamlanivimab is available only through the CATCO-NOS trial for patients with known native strain or alpha variant COVID. Criteria for trial inclusion: age ≥18 years, inpatient day 3 or more for non-COVID related diagnosis, confirmed COVID-19 positive within past 6 days, asymptomatic or symptoms < 6 days. Exclusion criteria: C1/C2 level of care, O2 >15 lpm, obstetric or psychiatric admission, pregnancy or breast feeding, allergy to bamlanivimab. To refer a patient, see CATCO - NOS trial for patients with nosocomial COVID-19 infection.
- Casirivimab/imdevimab is approved for use in AHS for patients hospitalized due to laboratory-confirmed COVID-19 if they weigh at least 40 kg and are aged 12 or older. They are eligible for treatment if: (1) if they have no documented history of COVID-19 infection, have not previously received treatment with a COVID-19 neutralizing antibody (except bamlanivimab monotherapy), and have not received any doses of a COVID-19 vaccine (unless fewer than 14 days have elapsed since receiving their first dose), AND they test negative on a COVID-19 lab-based or rapid serology test, or (2) if they are severely immunocompromised. The definition of severely immunocompromised is taken from the AHS Infection Prevention and Control Management of Severely Immunocompromised COVID-19 Patients document.
The dosage of casirivimab/imdevimab for inpatients is 4 g/4 g which can be obtained using 3 kits of the commercially available product, to yield 33.3 mL (3996 mg) of each ingredient, which rounds to 4 g.
Casirivimab/imdevimab can also be accessed for patients hospitalized for non-COVID reasons who acquire COVID in hospital, via the CATCO-NOS trial. To refer a patient, see CATCO - NOS trial for patients with nosocomial COVID-19 infection.
Casirivimab/imdevimab is not currently approved for outpatient use in AHS.
- Consideration of all other investigational antivirals or immunomodulators (e.g. lopinavir/ritonavir, famotidine, baricitinib, and colchicine) should be only under ethics-approved, controlled trials.
- The use of hydroxychloroquine, or any hydroxychloroquine combinations (e.g. hydroxychloroquine plus azithromycin), convalescent plasma, and ivermectin 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 patients with severe COVID-19 but not critically ill, do not routinely add antibacterials unless bacterial infection is strongly suspected.
- For critically ill patients with suspected or confirmed severe COVID-19, empiric antibacterial agents to treat all likely pathogens causing severe acute respiratory bacterial infection and sepsis as soon as possible are reasonable, and optimally should be initiated 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.