Current Treatment Approach for Inpatient COVID-19
The cornerstone of inpatient COVID-19 treatment includes antiviral therapy with remdesivir, dexamethasone for patients requiring oxygen, and appropriate anticoagulation based on patient risk factors. The management strategy should be tailored according to disease severity, with specific considerations for thromboprophylaxis, respiratory support, and potential complications.
Antiviral Therapy
- Remdesivir is indicated for hospitalized COVID-19 patients regardless of severity:
- For patients not requiring mechanical ventilation: 200 mg IV loading dose on day 1, followed by 100 mg IV daily for 4 days (5-day total course) 1
- For patients requiring mechanical ventilation or ECMO: 10-day total treatment course 1
- Should be initiated as soon as possible after diagnosis 1
- Monitor hepatic function and prothrombin time before starting and during treatment 1
Anti-inflammatory Therapy
- Dexamethasone 6 mg daily for up to 10 days for patients requiring oxygen supplementation 2
- Tocilizumab should be considered for patients with elevated inflammatory markers who are rapidly deteriorating despite corticosteroid therapy 2
Anticoagulation Management
For non-ICU hospitalized patients:
- Prophylactic-dose low-molecular-weight heparin (LMWH) should be administered to all patients without contraindications 3
- Patients on antiplatelet therapy for previous stroke should continue their antiplatelet therapy with addition of prophylactic-dose LMWH 3
- Patients with atrial fibrillation should receive therapeutic-dose parenteral anticoagulation regardless of CHA₂DS₂-VASc score 3, 2
For ICU patients:
- Consider intensified VTE prophylaxis (intermediate or half-therapeutic LMWH dosage) for patients with additional risk factors (BMI >30 kg/m², history of VTE, thrombophilia, active cancer) 3
- For confirmed VTE, therapeutic-dose LMWH is the standard of care 3
- In cases of severe renal insufficiency, unfractionated heparin should be used 3
Extended thromboprophylaxis:
Respiratory Support
- Patients with hypoxemia (SpO₂ <90%) despite oxygen therapy, dyspnea, or high respiratory rate should be considered for ICU admission 4
- For hypoxemic respiratory insufficiency, attempt high-flow oxygen or non-invasive ventilation first 4
- Patients with severe hypoxemia or high respiratory rate should undergo intubation and invasive ventilation 4
Antimicrobial Stewardship
- Restrict antimicrobial drugs in patients with mild-to-moderate COVID-19, especially those with low procalcitonin levels (<0.25 ng/mL) 2
- Avoid prescribing antibiotics without evidence of bacterial co-infection 2
- If bacterial infection is suspected, obtain cultures and initiate empiric antibiotics with prompt de-escalation based on culture results 3
Infection Control Measures
- Implement strict isolation protocols for confirmed COVID-19 patients 2
- Healthcare workers should use appropriate PPE including N95/FFP2 respirators during aerosol-generating procedures 2
- Dedicate specific areas/rooms for COVID-19 patients to minimize transmission risk 3
Monitoring and Supportive Care
- Monitor for clinical deterioration: temperature ≥38°C, subjective shortness of breath, tachypnea (>20 breaths/min), and hypoxia 2
- Maintain adequate oxygenation with supplemental oxygen as needed 4
- Consider multidisciplinary approach for complex cases, especially for patients requiring mechanical ventilation or with signs of septic shock 3
Post-Acute Care Considerations
- Monitor for persistent symptoms and consider referral to specialists if symptoms persist beyond 12 weeks 2
- For patients discharged on anticoagulation, ensure appropriate transition to oral agents when indicated 3
This evidence-based approach to inpatient COVID-19 management focuses on antiviral therapy, anti-inflammatory treatment, appropriate anticoagulation, respiratory support, and infection control to reduce mortality and improve outcomes.