What to do for a Covid-19 positive patient with persistent fever?

Management of COVID-19 Positive Patient with Persistent Fever

For a COVID-19 positive patient with persistent fever, administer paracetamol for symptomatic relief, ensure adequate hydration (up to 2 liters daily), and monitor for signs of clinical deterioration requiring hospital admission. 1

Initial Assessment and Home Management

Fever Management

• Do not use antipyretics with the sole aim of reducing body temperature
• Administer paracetamol if fever is causing distress or accompanied by other symptoms 1
• Continue paracetamol only while symptoms persist
• Paracetamol is preferred over NSAIDs for COVID-19 patients 1

Hydration

• Advise regular fluid intake to avoid dehydration
• Limit to no more than 2 liters per day 1
• Monitor for signs of dehydration (dry mouth, decreased urine output, dizziness)

Monitoring Parameters

Monitor for signs of clinical deterioration requiring hospitalization:

• Worsening respiratory symptoms
• Shortness of breath at rest or with minimal exertion
• Inability to maintain oral hydration
• Persistent high fever (>39°C) unresponsive to antipyretics
• Altered mental status
• Oxygen saturation <94% (if monitoring available)

Indications for Hospital Admission

Consider hospital admission if the patient develops:

1. Hypoxemia (SpO2 <90%) despite supplemental oxygen
2. Respiratory rate >30 breaths/minute
3. Significant dyspnea
4. Signs of severe disease or complications 2

Special Considerations

• Older patients or those with comorbidities are at higher risk for developing severe pneumonia 1
• Patients with chronic liver disease may require closer monitoring 1
• Immunocompromised patients may need earlier intervention 1

Hospital Management (If Required)

Initial Interventions

• Test all patients for SARS-CoV-2 on admission (even if previously positive) 1
• Initiate oxygen therapy for hypoxemic patients
• Consider high-flow nasal oxygen or non-invasive CPAP for patients with acute hypoxemic respiratory failure without immediate indication for invasive ventilation 3

Pharmacological Management

• Dexamethasone 6 mg daily for patients requiring oxygen therapy 3
• Consider remdesivir for patients with moderate COVID-19 requiring oxygen but not invasive mechanical ventilation 3, 4
• Tocilizumab may be considered for patients with worsening disease and evidence of systemic inflammation 3
• Administer prophylactic anticoagulation with LMWH to reduce thromboembolic risk 1

Supportive Care

• Consider liberal use of growth factor support in patients without COVID-19 to maintain neutrophil count >1000 cells/μL 1
• Monitor liver function tests and prothrombin time before and during remdesivir treatment 4
• For patients with cough, consider positioning (avoid lying on back), honey (for patients >1 year), or if distressing, short-term use of codeine linctus or morphine sulfate oral solution 1

Discharge Criteria

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

Important Caveats

Fever Considerations

• Fever typically peaks around day 5 after exposure to infection 1
• Some research suggests that fever may play a beneficial role in the immunological response to COVID-19, and excessive antipyretic use might prolong illness 5

Medication Interactions

• Monitor for drug-drug interactions between COVID-19 therapies and other medications 1
• Avoid hydroxychloroquine due to lack of efficacy and potential harm 3
• Avoid azithromycin unless bacterial infection is suspected 3

Thromboprophylaxis

• All hospitalized COVID-19 patients should receive thromboprophylaxis 1, 3
• Consider higher doses for patients with additional risk factors 3

Remember that early intervention with appropriate supportive care is crucial for managing COVID-19 patients with persistent fever, and decisions regarding hospitalization should be made promptly when indicated by clinical deterioration.