What is the management of patients with COVID-19 (Coronavirus Disease 2019) requiring hospital admission?

Management of Patients with COVID-19 Requiring Hospital Admission

Hospitalized COVID-19 patients should receive corticosteroids (dexamethasone 6mg daily for 10 days) if requiring oxygen, anticoagulation prophylaxis, and consideration of remdesivir based on oxygen requirements. 1, 2

Initial Assessment and Stratification

• Test all patients for SARS-CoV-2 before or upon admission
• Isolate patients in a single room until test results are available
• Stratify treatment based on oxygen requirements:
  • Not requiring supplemental oxygen
  • Requiring supplemental oxygen (non-invasive)
  • Requiring mechanical ventilation or ECMO

Pharmacological Management

Corticosteroids

• Strong recommendation for corticosteroids in patients requiring oxygen, non-invasive ventilation, or mechanical ventilation 1

  • Dexamethasone 6mg daily for 10 days
  • Reduces mortality significantly in patients requiring oxygen (23.3% vs 26.2%) and mechanical ventilation (29.3% vs 41.4%)

• Strong recommendation AGAINST corticosteroids in patients NOT requiring oxygen 1, 2

  • May increase mortality in non-hypoxic patients

Anticoagulation

• Strong recommendation for anticoagulation prophylaxis in all hospitalized COVID-19 patients 1
  • Use LMWH at prophylactic dosage
  • Consider higher doses for patients with additional risk factors (BMI >30, history of VTE, active cancer)
  • Adjust dosage according to renal function and bleeding risk
  • Consider extended prophylaxis after discharge for patients with persistent immobility or high inflammatory markers

Antiviral Therapy

• Consider remdesivir for patients with moderate COVID-19 requiring oxygen with saturation >90% 2
  • Dosing: 200mg IV on day 1, followed by 100mg daily for 4-9 days
  • Most beneficial when initiated early in disease course 3
  • No recommendation for patients not requiring mechanical ventilation 1
  • Conditional recommendation against remdesivir in patients requiring invasive mechanical ventilation 1

IL-6 Receptor Antagonists

• Conditional recommendation for IL-6 receptor antagonists (tocilizumab) in patients requiring oxygen or ventilatory support 1, 4
  • Most effective when combined with corticosteroids
  • FDA-approved for hospitalized COVID-19 patients receiving systemic corticosteroids who require supplemental oxygen, non-invasive or invasive mechanical ventilation, or ECMO 4
  • Not recommended for patients not requiring oxygen

Medications NOT Recommended

• Strong recommendations AGAINST:

  • Hydroxychloroquine 1
  • Lopinavir-ritonavir 1

• Conditional recommendations AGAINST:

  • Azithromycin (unless bacterial infection is present) 1, 2
  • Hydroxychloroquine + azithromycin combination 1
  • Colchicine 1
  • Interferon-β 1

Respiratory Support

• Conditional recommendation for high-flow nasal cannula (HFNC) or non-invasive CPAP for patients with hypoxemic respiratory failure without immediate indication for invasive mechanical ventilation 1
  • Can be delivered through helmet or facemask
  • Requires supervision by clinicians capable of performing endotracheal intubation if patient deteriorates

Management of Co-infections

• Consider possible hospital-acquired pneumonia in deteriorating patients
• Do not routinely administer antibiotics unless bacterial infection is clinically suspected 2
• If antibiotics are needed, follow standard guidelines for hospital-acquired or ventilator-associated pneumonia

Special Considerations

• For patients with IBD and COVID-19, admission decisions should consider both the severity of COVID-19 and IBD 1
• Thromboprophylaxis should be adapted to each situation, especially in patients with IBD who are already at risk for thromboembolic complications 1
• Monitor for liver function abnormalities, which are common in COVID-19 and may indicate higher risk for severe disease 2

Discharge Criteria

• Resolution of fever for >3 days
• Improvement of respiratory symptoms
• Significant absorption of pulmonary lesions on imaging 2

Common Pitfalls to Avoid

1. Inappropriate use of corticosteroids in patients not requiring oxygen
2. Delayed initiation of anticoagulation prophylaxis
3. Unnecessary antibiotic use without evidence of bacterial infection
4. Premature discharge before clinical improvement is established
5. Failure to adjust immunosuppressive medications in patients with autoimmune conditions

By following this evidence-based approach to managing hospitalized COVID-19 patients, clinicians can optimize outcomes while minimizing risks associated with inappropriate treatments.