What are the treatment guidelines for COVID-19?

COVID-19 Treatment Guidelines

COVID-19 treatment should be tailored according to disease severity, with antibiotics avoided unless clinically justified, and specific antiviral therapies like remdesivir reserved for appropriate patients based on hospitalization status and risk factors.

Disease Classification and Severity Assessment

Disease severity guides treatment decisions and is categorized as:

• Mild illness: Various symptoms (fever, upper respiratory symptoms, GI symptoms) without respiratory distress or abnormal imaging
• Moderate illness: Lower respiratory disease with SpO2 ≥94% on room air
• Severe illness: SpO2 <94% on room air, PaO2/FiO2 <300 mmHg, respiratory rate >30 breaths/min, or lung infiltrates >50%
• Critical illness: Requires ICU admission or mechanical ventilation 1

General Treatment Principles

Antibiotics Management

• Avoid routine antibiotics in COVID-19 patients (Strong recommendation, moderate quality evidence)
• Only prescribe antibiotics based on clinical justification including disease manifestations, severity, imaging, and laboratory data 1
• Perform comprehensive microbiologic workup before starting empirical antibiotics to facilitate adjustment or discontinuation 1

Antiviral Therapy

Remdesivir (Veklury)

• Hospitalized patients:

  • Loading dose: 200 mg IV on Day 1
  • Maintenance dose: 100 mg IV daily from Day 2
  • Duration: 5 days for non-ventilated patients; may extend to 10 days if no clinical improvement
  • For ventilated/ECMO patients: 10 days total 2

• Non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression:

  • Start within 7 days of symptom onset
  • 3-day treatment course 2

• Pediatric dosing (for patients ≥1.5 kg):

  • <28 days old: 2.5 mg/kg loading dose, then 1.25 mg/kg daily
  • ≥28 days old and <40 kg: 5 mg/kg loading dose, then 2.5 mg/kg daily 2

Favipiravir

• Used in some countries (Japan, Russia, Saudi Arabia, Thailand) for mild to moderate COVID-19
• Dosing varies by country guidelines:
  • Japanese recommendation: 3600 mg (1800 mg BID) on day 1, then 1600 mg (800 mg BID) for up to 14 days
  • Russian recommendation: Weight-based dosing with 1600-2400 mg BID on day 1, then 600-1000 mg BID for days 2-10 1

Corticosteroids

• Dexamethasone 6 mg daily for up to 10 days is recommended for hospitalized patients requiring oxygen 3

Management Based on Disease Severity

Mild to Moderate Disease (Outpatient)

• Primary approach: Supportive care and symptomatic treatment
• Monitoring: Temperature, respiratory rate, oxygen saturation
• Isolation: Maintain until at least 3 days with no fever, significant improvement in respiratory symptoms, and at least 10 days since symptom onset 3
• Consider antiviral therapy for high-risk patients (remdesivir if within 7 days of symptom onset) 2

Severe Disease (Hospitalized)

• Oxygen therapy: For patients with SpO2 <94%
• Anticoagulation: Consider intensified prophylaxis with additional risk factors (obesity, known thrombophilia, ICU treatment, elevated D-dimers) 4
• Remdesivir: For patients requiring oxygen but not invasive mechanical ventilation 2
• Dexamethasone: 6 mg daily for up to 10 days 3, 4
• Consider IL-6 inhibitors (tocilizumab, sarilumab) for patients with worsening respiratory status and elevated inflammatory markers 3

Critical Disease (ICU)

• Ventilation strategy: Consider high-flow oxygen or non-invasive ventilation initially; proceed to intubation for severe hypoxemia or high respiratory rate 4
• Anticoagulation: Enhanced thromboprophylaxis 3
• Dexamethasone: Continue 6 mg daily 3, 4
• Prone positioning: For mechanically ventilated patients with severe ARDS

Laboratory Monitoring

• Perform hepatic laboratory testing before starting and during treatment with remdesivir 2
• Monitor prothrombin time before and during remdesivir treatment 2
• For hospitalized patients: Complete blood count, CRP, PCT, liver enzymes, renal function, and coagulation parameters 3

Special Considerations

COVID-19 Associated Infections

• Bacterial infections: Higher risk in critically ill patients; consider empirical antibiotics based on clinical presentation, not solely on biomarkers 1
• Fungal infections: Monitor for COVID-19 associated candidiasis (CAC) and mucormycosis (CAM), especially in severely immunocompromised patients 1

Treatments to Avoid

• Hydroxychloroquine, azithromycin (unless bacterial infection is present), lopinavir-ritonavir, interferon-β, and colchicine are not recommended due to lack of efficacy and potential harm 3

Pitfalls and Caveats

• Don't rely solely on biomarkers (WBC, CRP, PCT) to decide on antimicrobial therapy, especially in non-critically ill patients 1
• Avoid routine antibiotics for patients receiving immunomodulatory agents (corticosteroids, IL-6 inhibitors) without evidence of bacterial infection 1
• Remdesivir should only be administered in settings with immediate access to medications for treating severe reactions 2
• Monitor for signs of thromboembolism (stroke, DVT, PE, acute coronary syndrome) due to increased risk in COVID-19 patients 3