What are the current recommendations for managing COVID-19 (Coronavirus Disease 2019)?

Current COVID-19 Management Recommendations

The most current recommendations for COVID-19 management include vaccination for all eligible individuals aged ≥6 months, early antiviral treatment with nirmatrelvir-ritonavir for high-risk patients, and symptom management based on disease severity. 1, 2

Diagnosis and Initial Assessment

• Test all symptomatic patients for SARS-CoV-2 before initiating treatment
• Assess oxygen requirements and evaluate for risk factors for disease progression:
  • Age ≥65 years
  • Obesity
  • Cardiovascular disease
  • Chronic lung disease
  • Immunocompromised status
  • Diabetes
  • Chronic kidney disease 1

Disease Severity Classification

The World Health Organization categorizes COVID-19 severity as:

Category	Criteria
Mild	Various symptoms without respiratory distress
Moderate	Lower respiratory disease and SpO2 ≥94% on room air
Severe	SpO2 <94% on room air
Critical	Requires ICU admission or mechanical ventilation [1]

Treatment Recommendations

Antiviral Therapy

• Nirmatrelvir-ritonavir (Paxlovid) is recommended for high-risk patients with mild-to-moderate COVID-19:
  • Standard dosing: 300 mg nirmatrelvir (two 150 mg tablets) with 100 mg ritonavir (one 100 mg tablet) twice daily for 5 days
  • For moderate renal impairment (eGFR 30-59 mL/min): 150 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days
  • For severe renal impairment (eGFR <30 mL/min): 300 mg nirmatrelvir with 100 mg ritonavir once on day 1, then 150 mg nirmatrelvir with 100 mg ritonavir once daily for days 2-5 1, 3

Important warning: Nirmatrelvir-ritonavir has significant drug interactions due to ritonavir's strong CYP3A4 inhibition. Review all medications and determine if dose adjustments, interruption, or additional monitoring is needed 3

• If nirmatrelvir-ritonavir is contraindicated, molnupiravir may be considered for high-risk patients when other options are unavailable 1

Symptomatic Management

Cough Management

• Encourage patients to avoid lying on their back as this makes coughing ineffective
• Consider honey for patients aged over 1 year
• For distressing cough, consider short-term use of codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution 4

Fever Management

• Maintain hydration
• Use paracetamol for fever relief 1

Bacterial and Fungal Co-infections

• Empirical antibiotics are not routinely recommended for non-critically ill patients 4

• For critically ill patients:

  • Consider empirical anti-MRSA antibiotics for pulmonary bacterial co-infections 4
  • Single anti-pseudomonal antibiotic is recommended for non-critically ill patients with secondary bacterial infections 4
  • Double anti-pseudomonal antibiotics and/or anti-MRSA antibiotics may be considered for critically ill patients based on local epidemiology 4

• For fungal infections:

  • Routine antifungal prophylaxis is not recommended 4
  • For confirmed COVID-19-associated pulmonary aspergillosis (CAPA), treat with voriconazole, isavuconazole, posaconazole, or liposomal amphotericin B 4

Vaccination Recommendations

• Updated COVID-19 vaccines are recommended for all persons aged ≥6 months 2
• The most recent formulations target XBB.1.5 variant and provide broader protection against currently circulating SARS-CoV-2 variants 2
• Vaccine effectiveness data shows:
  • For adults without immunocompromising conditions: 62% effectiveness against hospitalization in first 7-59 days after vaccination
  • For adults with immunocompromising conditions: 28% effectiveness in the same period
  • Protection against critical outcomes (ICU admission or death) is sustained through at least 179 days 5

Special Populations

Immunocompromised Patients

• Vaccination is a high priority but may have reduced effectiveness 4
• Consider adjusting immunosuppressive medications around vaccination time when possible 4
• More vigilant monitoring for disease progression is recommended 1

Patients with Renal Impairment

• Adjust nirmatrelvir-ritonavir dosing based on renal function 3
• On hemodialysis days, administer PAXLOVID after hemodialysis 3

Patients with Hepatic Impairment

• PAXLOVID is not recommended in patients with severe hepatic impairment (Child-Pugh Class C) 3
• Monitor liver function closely in all patients 1

Treatment Escalation and Follow-up

• Put treatment escalation plans in place as patients may deteriorate rapidly 4
• Schedule virtual follow-up 1-2 weeks after diagnosis 1
• Discharge criteria include:
  • Temperature returned to normal for more than 3 days
  • Respiratory symptoms significantly improved
  • Significant absorption of pulmonary lesions on CT imaging
  • Two consecutive negative nucleic acid tests from respiratory tract samples (at least 24 hours apart) 1

Common Pitfalls to Avoid

• Underestimating secondary infections can lead to poor outcomes - monitor closely for signs of bacterial or fungal superinfection 1
• Missing coagulation abnormalities - consider appropriate anticoagulation based on risk assessment 1
• Drug interactions with nirmatrelvir-ritonavir can be serious or life-threatening - thoroughly review all medications before prescribing 3
• Delaying antiviral treatment reduces effectiveness - initiate treatment as soon as possible after diagnosis and within 5 days of symptom onset 3