What is the treatment (tx) of COVID-19 pneumonia?

Treatment of COVID-19 Pneumonia

Immunomodulatory therapy, specifically dexamethasone, is the cornerstone of treatment for severe COVID-19 pneumonia requiring oxygen, while remdesivir should be administered early in the disease course for patients at high risk for progression to severe disease. 1, 2

Treatment Algorithm Based on Disease Severity

Mild-to-Moderate COVID-19 Pneumonia (Outpatient)

• Antiviral therapy: Remdesivir 200mg IV on day 1, followed by 100mg IV daily for 2 additional days (total 3-day course)
  • Indicated for patients with risk factors for progression to severe disease
  • Must be initiated within 7 days of symptom onset 3
• Supportive care: Adequate hydration, nutrition, and antipyretics as needed

Severe COVID-19 Pneumonia (Hospitalized, requiring oxygen)

• Corticosteroids: Dexamethasone 6mg IV or oral daily for up to 10 days 1, 2
• Antiviral therapy: Remdesivir 200mg IV on day 1, followed by 100mg IV daily
  • 5-day course for patients not requiring mechanical ventilation
  • Consider extending to 10 days if no clinical improvement 3
• Anticoagulation: Low-molecular-weight heparin for thromboprophylaxis unless contraindicated 1, 4
• Respiratory support:
  • Low-flow oxygen for mild hypoxemia
  • High-flow nasal cannula (HFNC) for moderate hypoxemia 2
  • Consider prone positioning to improve oxygenation 4

Critical COVID-19 Pneumonia (ICU, requiring mechanical ventilation/ECMO)

• Continue dexamethasone 6mg daily for up to 10 days 1, 2
• Complete remdesivir course if already initiated (10-day total) 3
• Lung-protective ventilation: Low tidal volume (6 mL/kg predicted body weight) and PEEP titration 2
• Anticoagulation: Continue thromboprophylaxis 1

Management of Bacterial Co-infection

• Empiric antibiotics are not routinely recommended for all patients with confirmed COVID-19 pneumonia 1
• Consider empiric antibiotics if:
  • Clinical suspicion of bacterial co-infection
  • Elevated procalcitonin (though not perfectly specific)
  • Worsening after initial improvement 1
• If antibiotics are initiated:
  • Obtain blood and sputum cultures when possible
  • Target common respiratory pathogens (Streptococcus pneumoniae, Haemophilus influenzae)
  • Limit duration to 5 days if no evidence of bacterial infection 1
  • Consider early discontinuation with low procalcitonin values 1

Nutritional Support

• Screen hospitalized patients using NRS2002 score
• For patients with score <3: Protein-rich diet with 25-30 kcal/kg/day and 1.5g/kg/day protein
• For patients with score ≥3: Add oral nutritional supplements 2-3 times/day (≥18g protein/time)
• Consider enteral nutrition tube if unable to meet requirements orally 1

Important Considerations and Pitfalls

• Timing matters: Remdesivir shows greatest benefit when initiated early in the disease course, particularly within 7 days of symptom onset 3
• Corticosteroid timing: Dexamethasone benefits patients requiring oxygen but may be harmful if used too early in mild disease not requiring oxygen 1, 2
• Respiratory support escalation: Don't delay intubation if patient shows signs of increased work of breathing despite noninvasive support 4
• Monitor for complications: Regularly assess for thromboembolic events, secondary bacterial infections, and organ dysfunction 1, 5
• Post-COVID recovery: Anticipate potential long-term physical and cognitive impairments, especially in patients who developed ARDS 2

The evidence for COVID-19 treatment has evolved significantly since the beginning of the pandemic. While early guidelines recommended against immunomodulatory therapy 1, more recent evidence strongly supports the use of dexamethasone for patients requiring oxygen 1, 2. Similarly, remdesivir has demonstrated benefit in reducing time to recovery and potentially preventing progression to severe disease when used early 3.