What is the best management approach for inpatient COVID-19 (Coronavirus Disease 2019) workup and treatment?

Inpatient COVID-19 Management: Workup and Treatment

For hospitalized COVID-19 patients, implement a severity-stratified treatment approach: all patients should receive prophylactic anticoagulation with LMWH; patients requiring oxygen should receive dexamethasone 6 mg daily for 10 days; and remdesivir should be administered to those not on mechanical ventilation, with treatment duration of 5 days for non-ventilated patients and 10 days for those requiring invasive mechanical ventilation/ECMO. 1, 2

Initial Workup and Diagnostic Approach

Clinical Assessment

• Maintain high index of suspicion for any patient with severe acute respiratory infection, as clinical features are non-specific and risk of missing cases early in local outbreaks is substantial 3
• Key clinical features to assess: fever, respiratory symptoms (cough, dyspnea), oxygen saturation, respiratory rate >30 breaths/min, and presence of bilateral lung infiltrates 3
• Severity classification 3, 1:
  • Moderate: SpO2 ≥94% on room air with evidence of lower respiratory disease
  • Severe: SpO2 <94% on room air, PaO2/FiO2 <300 mmHg, respiratory rate >30/min, or lung infiltrates >50%
  • Critical: ICU admission criteria, mechanical ventilation requirement, ARDS, or septic shock

Laboratory Testing

• RT-PCR testing for SARS-CoV-2 confirmation, though sensitivity in critically ill patients is unknown 3
• Comprehensive microbiologic workup before empirical antibiotics to facilitate de-escalation 3
• Baseline laboratory markers 3:
  • Complete blood count (elevated WBC may indicate bacterial coinfection)
  • C-reactive protein and procalcitonin (PCT >0.5 ng/mL suggests higher possibility of bacterial infection)
  • D-dimer (elevated levels associated with worse outcomes and VTE risk)
  • Hepatic function tests (required before and during remdesivir therapy) 2
  • Prothrombin time 2

Imaging

• Chest radiograph as first-line for acute lung processes 3
• CT findings: bilateral ground glass opacities and consolidation are common 3

Treatment Based on Disease Severity

Moderate COVID-19 (Requiring Oxygen but Not Mechanical Ventilation)

Antiviral Therapy

• Remdesivir is recommended 1, 2:
  • Loading dose: 200 mg IV on Day 1
  • Maintenance: 100 mg IV daily from Day 2
  • Duration: 5 days (may extend to 10 days if no clinical improvement)
  • Must be initiated as soon as possible after diagnosis 2

Corticosteroid Therapy

• Dexamethasone 6 mg daily for 10 days is strongly recommended 3, 1
• This showed 3% reduction in mortality in patients requiring oxygen therapy 3
• Critical caveat: Do NOT use corticosteroids in patients not requiring oxygen, as this can be harmful 1

Immunomodulatory Therapy

• If worsening despite dexamethasone with COVID-19-related inflammation, add anti-IL-6 agents (tocilizumab or sarilumab) 3, 1
• For seronegative patients, consider casirivimab/imdevimab or convalescent plasma 3

Severe/Critical COVID-19 (Mechanical Ventilation or ICU)

Corticosteroid Therapy

• Dexamethasone is strongly recommended as primary therapy 3, 1

Antiviral Therapy

• Remdesivir 2:
  • Loading dose: 200 mg IV on Day 1
  • Maintenance: 100 mg IV daily from Day 2
  • Duration: 10 days for patients on invasive mechanical ventilation/ECMO 2
  • Important note: Some guidelines suggest against remdesivir for patients requiring invasive mechanical ventilation 1

Immunomodulatory Therapy

• Addition of second immunosuppressant recommended if COVID-19-related inflammation present 1
• Anti-IL-6 agents (tocilizumab, sarilumab) are preferred 3, 1

Respiratory Support

• High-flow nasal cannula (HFNC) or noninvasive CPAP suggested for hypoxemic respiratory failure without immediate indication for intubation 1
• Intubation poses viral transmission risk to healthcare workers; use appropriate PPE 3
• ECMO is extremely resource-intensive even when centralized 3

Universal Inpatient Management Principles

Anticoagulation (Critical for All Hospitalized Patients)

• Prophylactic LMWH is strongly recommended for all hospitalized COVID-19 patients as soon as possible 3, 1
• Dosing considerations 3:
  • Standard: LMWH at dosage approved for high-risk situations
  • Intensified prophylaxis for patients with BMI >30 kg/m², history of VTE, thrombophilia, active cancer, ICU admission, or rapidly increasing D-dimer (intermediate or half-therapeutic dosing)
  • Adjust based on renal function, bleeding risk, and weight 3
• For established VTE: therapeutic-dose LMWH (or unfractionated heparin if severe renal insufficiency) 3
• Post-discharge prophylaxis: Consider extended duration (14-30 days) for high-risk patients with persistent immobility or high inflammatory activity 3

Antibiotic Stewardship

• Do NOT routinely prescribe antibiotics in COVID-19 patients 3
• Indications for antibiotics 3:
  • Clinical justification based on disease manifestations, severity, imaging, and laboratory data
  • Critically ill patients (ICU or mechanically ventilated) have higher risk of bacterial coinfection 3
  • PCT >0.5 ng/mL may indicate bacterial infection, but do not use biomarkers alone to decide 3

When Bacterial Infection Suspected:

• Non-critically ill/non-ICU pulmonary coinfection: Cover typical and atypical CAP pathogens 3
• Critically ill/ICU pulmonary coinfection: Consider adding anti-MRSA coverage 3
• Pulmonary secondary infection (non-ICU): Single antipseudomonal antibiotic 3
• Pulmonary secondary infection (ICU): Consider double antipseudomonal and/or anti-MRSA based on local epidemiology 3
• Always obtain cultures before antibiotics and de-escalate as soon as possible 3

Antifungal Considerations

• Only consider empirical antifungal in critically ill patients with fever of unknown origin and new pulmonary infiltrate superimposed on viral pneumonitis 3
• Confirm diagnosis with invasive techniques and/or fungal biomarkers 3

Treatments NOT Recommended

• Hydroxychloroquine is strongly recommended against 1
• Azithromycin should not be used in absence of bacterial infection 1
• Lopinavir-ritonavir is strongly recommended against 1
• Do NOT use corticosteroids in patients not requiring oxygen 1

Special Monitoring and Complications

Common Complications to Monitor

• ARDS (60-70% of ICU patients) 3
• Shock (30% of ICU patients) 3
• Myocardial dysfunction (20-30%) - patients often develop cardiac complications in addition to respiratory failure 3
• Acute kidney injury (10-30%) 3
• Arrhythmia (44% of ICU patients) 3
• Secondary bacterial/fungal infections 3

Infection Control

• Isolate confirmed COVID-19 patients from negative patients 3
• Healthcare workers require trained use of complete PPE (N95 masks, goggles, double gloves, face shields, protective gowns) 3
• Keep cathlab/procedure room doors closed at all times during procedures 3

Key Clinical Pitfalls to Avoid

1. Do not delay anticoagulation - initiate prophylactic LMWH immediately upon admission 3
2. Do not give corticosteroids to patients not requiring oxygen - this causes harm 1
3. Do not routinely prescribe antibiotics - obtain cultures first and use only when clinically justified 3
4. Do not use biomarkers alone to decide antibiotic initiation, especially in non-critically ill patients 3
5. Do not forget hepatic monitoring with remdesivir therapy 2
6. Do not extend remdesivir beyond 10 days total duration 2
7. Elderly patients may develop hypoxemia without respiratory distress - monitor oxygen saturation closely 3